hospital_name,last_updated_on,version,location_name,hospital_address,license_number|MA,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
Newton Wellesley Hospital,2026-03-27,3.0.0,Newton Wellesley Hospital,2014 Washington St Newton MA 02462-1607,2075,1992737761,true,Daniel Morash
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","modifiers","setting","drug_unit_of_measurement","drug_type_of_measurement","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|min","standard_charge|max","standard_charge|methodology","additional_generic_notes"
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","325.00","243.75","AETNA [1001]","HB CH AETNA HMO / PPO","189.48","58.3","","179.17","179.17","179.17","1 through 10","37.73","308.75","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","325.00","243.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","237.25","73","","316.00","316.00","316.00","1 through 10","37.73","308.75","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.96","78.45","","242.94","143.97","242.94","1 through 10","39.7","254.96","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.11","73","","2044.40","2044.40","2044.40","1 through 10","83.7","1207","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","WELLPOINT [1015]","HB CH WELLPOINT","317.09","77.91","","103.18","103.18","103.18","437","83.7","1207","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","inpatient","","","407.00","305.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","227.92","56","","1738.34","1738.34","1738.34","1 through 10","227.92","287.34","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.71","49.07","","353.80","216.44","865.75","1302","163.69","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","203.91","50.1","","353.24","218.18","741.80","1897","163.69","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.35","59.3","","1151.49","245.58","3144.00","203","163.69","5129.31","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","262.38","52.2","","258.86","258.86","258.86","1 through 10","223.42","766.62","percent of total billed charges",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","26213.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11992.50","","Standard inlier is a Case rate ($11,992.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,100, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,702.29) for the length of stay and the standard reimbursement.","11992.50","11992.50","11992.50","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","26213.02","","MASSHEALTH [3001]","HB NWH MEDICAID","4618.59","","Case rate ($4,975.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,405.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1516.29","1516.29","1516.29","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","26213.02","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4618.59","","Case rate ($4,975.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,405.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4988.59","4988.59","4988.59","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","26015.42","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5450.23","","Case rate ($5,871.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,301.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5886.86","5886.86","5886.86","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","AETNA [1001]","HB CH AETNA HMO / PPO","1254.62","58.3","","1186.73","1186.73","1186.73","1 through 10","761.55","1676.62","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","1972.41","1972.41","1 through 10","761.55","1676.62","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","128","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1093.14","1091.14","3279.42","69","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.14","1098.14","1113.41","1 through 10","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","WELLPOINT [1015]","HB CH WELLPOINT","1676.62","77.91","","3741.45","1648.45","3741.45","1 through 10","761.55","1676.62","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","1231.42","1231.42","23","761.55","1873.9","other","ASC "
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","1233.17","1259.29","35","761.55","1873.9","other","ASC "
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","1789.64","3442.20","53","761.55","1873.9","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1881.03","1881.03","1881.03","1 through 10","761.55","1873.9","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1688.24","78.45","","1609.10","1609.10","1609.10","1 through 10","761.55","1873.9","percent of total billed charges",""
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0361","RC","","","","both","","","1631.00","1223.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1113.41","1093.64","1113.41","1 through 10","761.55","1270.71","other","OPPS APC"
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0761","RC","","","","outpatient","","","1631.00","1223.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","1231.42","1231.42","1 through 10","870.88","870.88","other","ASC "
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0761","RC","","","","outpatient","","","1631.00","1223.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1259.29","1259.29","1 through 10","870.88","870.88","other","ASC "
"Ablation Endometrial Thermal","PX-76001389","CDM","58353","CPT","0761","RC","","","","outpatient","","","8481.00","6360.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6822.40","6822.40","6822.40","1 through 10","3713.25","7178","other","ASC "
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","13805.00","10353.75","MEDICARE [2001]","HB NWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","4136.27","10755.48","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","13805.00","10353.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6789.39","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6797.58","6797.58","6797.58","1 through 10","4136.27","10755.48","other","OPPS APC"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","4687.96","3384.99","5990.92","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","1984.13","3888.77","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","3218.00","1 through 10","1984.13","3888.77","per diem",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1984.13","42.9","","4935.51","4935.51","4935.51","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3899.16","3899.16","1 through 10","2125.14","7939.38","other","ASC "
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","2125.14","7939.38","other","ASC "
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","4845.05","4845.05","4845.05","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14982.24","14982.24","14982.24","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6247.91","6247.91","6247.91","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","1692.50","1692.50","1692.50","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","1 through 10","2125.14","7939.38","other","ASC "
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","2125.14","7939.38","other","ASC "
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","10115.66","10115.66","10115.66","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","6121.00","2294.87","6121.00","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy,MINOR","543","DRG","","","","","","","","inpatient","","","30069.76","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4506.63","","Case rate ($4,855.19). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,285.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4254.43","4254.43","4254.43","1 through 10","4506.63","17430.47","case rate",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy,MODERATE","543","DRG","","","","","","","","inpatient","","","32963.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16226.48","","Standard inlier is a Case rate ($16,226.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,294, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,303.41) for the length of stay and the standard reimbursement.","15489.12","15489.12","15489.12","1 through 10","4506.63","17430.47","case rate",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","AETNA [1001]","HB CH AETNA HMO / PPO","1912.97","58.3","","1530.90","1160.93","1884.08","89","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1739.06","53","","5253.92","5253.92","5253.92","1 through 10","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1903.13","58","","12181.47","12181.47","12181.47","1 through 10","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2050.78","62.5","","1350.68","1350.68","1350.68","1 through 10","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1458.52","44.45","","1910.74","891.94","1910.74","1 through 10","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","WELLPOINT [1015]","HB CH WELLPOINT","2556.42","77.91","","1829.79","1561.50","2617.12","88","1458.52","2556.42","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3281.25","2460.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","1945.78","59.3","","1359.46","1201.30","1689.00","61","1640.63","2574.14","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3281.25","2460.94","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1945.78","59.3","","1718.92","1718.92","1718.92","1 through 10","1640.63","2574.14","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3281.25","2460.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2574.14","78.45","","1910.74","1019.06","2344.84","74","1640.63","2574.14","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","AETNA [1001]","HB CH AETNA HMO / PPO","1254.03","58.3","","1530.90","1160.93","1884.08","89","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1140.03","53","","5253.92","5253.92","5253.92","1 through 10","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1247.58","58","","12181.47","12181.47","12181.47","1 through 10","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1344.38","62.5","","1350.68","1350.68","1350.68","1 through 10","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","956.12","44.45","","1910.74","891.94","1910.74","1 through 10","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","WELLPOINT [1015]","HB CH WELLPOINT","1675.84","77.91","","1829.79","1561.50","2617.12","88","956.12","1675.84","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2151.00","1613.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1275.54","59.3","","1359.46","1201.30","1689.00","61","1075.5","1687.46","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2151.00","1613.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1275.54","59.3","","1718.92","1718.92","1718.92","1 through 10","1075.5","1687.46","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2151.00","1613.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1687.46","78.45","","1910.74","1019.06","2344.84","74","1075.5","1687.46","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1530.90","1160.93","1884.08","89","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","5253.92","5253.92","5253.92","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","12181.47","12181.47","12181.47","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1910.74","891.94","1910.74","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","1829.79","1561.50","2617.12","88","1066.8","1869.84","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1359.46","1201.30","1689.00","61","1200","1882.8","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1718.92","1718.92","1718.92","1 through 10","1200","1882.8","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1910.74","1019.06","2344.84","74","1200","1882.8","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","AETNA [1001]","HB CH AETNA HMO / PPO","3191.34","58.3","","1530.90","1160.93","1884.08","89","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2901.22","53","","5253.92","5253.92","5253.92","1 through 10","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3174.92","58","","12181.47","12181.47","12181.47","1 through 10","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3421.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2433.19","44.45","","1910.74","891.94","1910.74","1 through 10","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","WELLPOINT [1015]","HB CH WELLPOINT","4264.79","77.91","","1829.79","1561.50","2617.12","88","2433.19","4264.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5474.00","4105.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3246.08","59.3","","1359.46","1201.30","1689.00","61","2737","4294.35","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5474.00","4105.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3246.08","59.3","","1718.92","1718.92","1718.92","1 through 10","2737","4294.35","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5474.00","4105.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4294.35","78.45","","1910.74","1019.06","2344.84","74","2737","4294.35","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","1530.90","1160.93","1884.08","89","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.70","53","","5253.92","5253.92","5253.92","1 through 10","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2314.20","58","","12181.47","12181.47","12181.47","1 through 10","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2493.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.56","44.45","","1910.74","891.94","1910.74","1 through 10","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","1829.79","1561.50","2617.12","88","1773.56","3108.61","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1359.46","1201.30","1689.00","61","1995","3130.16","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1718.92","1718.92","1718.92","1 through 10","1995","3130.16","percent of total billed charges",""
"ACETABULAR CUP 60MM PINNACLE GRIPTION DP REVISION","SUP-ITM-10090301","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","1910.74","1019.06","2344.84","74","1995","3130.16","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1530.90","1160.93","1884.08","89","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","5253.92","5253.92","5253.92","1 through 10","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","12181.47","12181.47","12181.47","1 through 10","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","1350.68","1350.68","1350.68","1 through 10","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1910.74","891.94","1910.74","1 through 10","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","1829.79","1561.50","2617.12","88","733.43","1285.52","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1359.46","1201.30","1689.00","61","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","1718.92","1718.92","1718.92","1 through 10","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1910.74","1019.06","2344.84","74","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1530.90","1160.93","1884.08","89","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","5253.92","5253.92","5253.92","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","607.26","58","","12181.47","12181.47","12181.47","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","654.38","62.5","","1350.68","1350.68","1350.68","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","1910.74","891.94","1910.74","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","1829.79","1561.50","2617.12","88","465.39","815.72","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1359.46","1201.30","1689.00","61","523.5","821.37","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","620.87","59.3","","1718.92","1718.92","1718.92","1 through 10","523.5","821.37","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","1910.74","1019.06","2344.84","74","523.5","821.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","AETNA [1001]","HB CH AETNA HMO / PPO","1339.73","58.3","","1530.90","1160.93","1884.08","89","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1217.94","53","","5253.92","5253.92","5253.92","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1332.84","58","","12181.47","12181.47","12181.47","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1436.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.46","44.45","","1910.74","891.94","1910.74","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","WELLPOINT [1015]","HB CH WELLPOINT","1790.37","77.91","","1829.79","1561.50","2617.12","88","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1359.46","1201.30","1689.00","61","1149","1802.78","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1718.92","1718.92","1718.92","1 through 10","1149","1802.78","percent of total billed charges",""
"ACETABULAR INSERT F 28MM 0DEG IMPLANT SIZE TRIDENT CONSTRAINED 11","SUP-ITM-10026807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1802.78","78.45","","1910.74","1019.06","2344.84","74","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","AETNA [1001]","HB CH AETNA HMO / PPO","1340.61","58.3","","1530.90","1160.93","1884.08","89","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.74","53","","5253.92","5253.92","5253.92","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1333.71","58","","12181.47","12181.47","12181.47","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1437.19","62.5","","1350.68","1350.68","1350.68","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1022.13","44.45","","1910.74","891.94","1910.74","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","WELLPOINT [1015]","HB CH WELLPOINT","1791.54","77.91","","1829.79","1561.50","2617.12","88","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1359.46","1201.30","1689.00","61","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1718.92","1718.92","1718.92","1 through 10","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.96","78.45","","1910.74","1019.06","2344.84","74","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","1530.90","1160.93","1884.08","89","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","5253.92","5253.92","5253.92","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1270.20","58","","12181.47","12181.47","12181.47","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1368.75","62.5","","1350.68","1350.68","1350.68","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","1910.74","891.94","1910.74","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","1829.79","1561.50","2617.12","88","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1359.46","1201.30","1689.00","61","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32MM ALETEONXLE NEUTRAL GROUP 2","SUP-ITM-10319697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","1910.74","1019.06","2344.84","74","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","1530.90","1160.93","1884.08","89","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","5253.92","5253.92","5253.92","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1270.20","58","","12181.47","12181.47","12181.47","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1368.75","62.5","","1350.68","1350.68","1350.68","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","1910.74","891.94","1910.74","1 through 10","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","1829.79","1561.50","2617.12","88","973.46","1706.23","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1359.46","1201.30","1689.00","61","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE 23 IMPLANT EPOLY RINGLOC MROM 11","SUP-ITM-10023004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","1910.74","1019.06","2344.84","74","1095","1718.06","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","AETNA [1001]","HB CH AETNA HMO / PPO","1340.61","58.3","","1530.90","1160.93","1884.08","89","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.74","53","","5253.92","5253.92","5253.92","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1333.71","58","","12181.47","12181.47","12181.47","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1437.19","62.5","","1350.68","1350.68","1350.68","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1022.13","44.45","","1910.74","891.94","1910.74","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","WELLPOINT [1015]","HB CH WELLPOINT","1791.54","77.91","","1829.79","1561.50","2617.12","88","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1359.46","1201.30","1689.00","61","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1718.92","1718.92","1718.92","1 through 10","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32X48MM SIZE GG VIVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114231","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.96","78.45","","1910.74","1019.06","2344.84","74","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","AETNA [1001]","HB CH AETNA HMO / PPO","640.92","58.3","","1530.90","1160.93","1884.08","89","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","582.66","53","","5253.92","5253.92","5253.92","1 through 10","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","637.62","58","","12181.47","12181.47","12181.47","1 through 10","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","687.09","62.5","","1350.68","1350.68","1350.68","1 through 10","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.66","44.45","","1910.74","891.94","1910.74","1 through 10","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","WELLPOINT [1015]","HB CH WELLPOINT","856.50","77.91","","1829.79","1561.50","2617.12","88","488.66","856.5","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.91","59.3","","1359.46","1201.30","1689.00","61","549.68","862.44","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","651.91","59.3","","1718.92","1718.92","1718.92","1 through 10","549.68","862.44","percent of total billed charges",""
"ACETABULAR LINER 32X49MM EPSILON DURASUL HOODED","SUP-ITM-10110611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.44","78.45","","1910.74","1019.06","2344.84","74","549.68","862.44","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","AETNA [1001]","HB CH AETNA HMO / PPO","1339.73","58.3","","1530.90","1160.93","1884.08","89","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1217.94","53","","5253.92","5253.92","5253.92","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1332.84","58","","12181.47","12181.47","12181.47","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1436.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.46","44.45","","1910.74","891.94","1910.74","1 through 10","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","WELLPOINT [1015]","HB CH WELLPOINT","1790.37","77.91","","1829.79","1561.50","2617.12","88","1021.46","1790.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1359.46","1201.30","1689.00","61","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1718.92","1718.92","1718.92","1 through 10","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1802.78","78.45","","1910.74","1019.06","2344.84","74","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","AETNA [1001]","HB CH AETNA HMO / PPO","745.60","58.3","","1530.90","1160.93","1884.08","89","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","677.82","53","","5253.92","5253.92","5253.92","1 through 10","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","741.76","58","","12181.47","12181.47","12181.47","1 through 10","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","799.31","62.5","","1350.68","1350.68","1350.68","1 through 10","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","568.47","44.45","","1910.74","891.94","1910.74","1 through 10","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.90","959.17","WELLPOINT [1015]","HB CH WELLPOINT","996.39","77.91","","1829.79","1561.50","2617.12","88","568.47","996.39","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.90","959.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","758.39","59.3","","1359.46","1201.30","1689.00","61","639.45","1003.3","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.90","959.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","758.39","59.3","","1718.92","1718.92","1718.92","1 through 10","639.45","1003.3","percent of total billed charges",""
"ACETABULAR LINER 36X66 70MM 10DEG SHELL LONGEVITY REVISION","SUP-ITM-10120342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.90","959.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1003.30","78.45","","1910.74","1019.06","2344.84","74","639.45","1003.3","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1530.90","1160.93","1884.08","89","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","5253.92","5253.92","5253.92","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","607.26","58","","12181.47","12181.47","12181.47","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","654.38","62.5","","1350.68","1350.68","1350.68","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","1910.74","891.94","1910.74","1 through 10","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","1829.79","1561.50","2617.12","88","465.39","815.72","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1359.46","1201.30","1689.00","61","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","620.87","59.3","","1718.92","1718.92","1718.92","1 through 10","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 40X60MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","1910.74","1019.06","2344.84","74","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","AETNA [1001]","HB CH AETNA HMO / PPO","1775.85","58.3","","1530.90","1160.93","1884.08","89","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1614.41","53","","5253.92","5253.92","5253.92","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1766.71","58","","12181.47","12181.47","12181.47","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1903.78","62.5","","1350.68","1350.68","1350.68","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1353.97","44.45","","1910.74","891.94","1910.74","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","WELLPOINT [1015]","HB CH WELLPOINT","2373.18","77.91","","1829.79","1561.50","2617.12","88","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1359.46","1201.30","1689.00","61","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1718.92","1718.92","1718.92","1 through 10","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2389.63","78.45","","1910.74","1019.06","2344.84","74","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1530.90","1160.93","1884.08","89","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","5253.92","5253.92","5253.92","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","12181.47","12181.47","12181.47","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","1350.68","1350.68","1350.68","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1910.74","891.94","1910.74","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1829.79","1561.50","2617.12","88","933.45","1636.11","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1359.46","1201.30","1689.00","61","1050","1647.45","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1718.92","1718.92","1718.92","1 through 10","1050","1647.45","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1910.74","1019.06","2344.84","74","1050","1647.45","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","AETNA [1001]","HB CH AETNA HMO / PPO","1775.85","58.3","","1530.90","1160.93","1884.08","89","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1614.41","53","","5253.92","5253.92","5253.92","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1766.71","58","","12181.47","12181.47","12181.47","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1903.78","62.5","","1350.68","1350.68","1350.68","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1353.97","44.45","","1910.74","891.94","1910.74","1 through 10","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","WELLPOINT [1015]","HB CH WELLPOINT","2373.18","77.91","","1829.79","1561.50","2617.12","88","1353.97","2373.18","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1359.46","1201.30","1689.00","61","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1718.92","1718.92","1718.92","1 through 10","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2389.63","78.45","","1910.74","1019.06","2344.84","74","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","AETNA [1001]","HB CH AETNA HMO / PPO","1406.72","58.3","","1530.90","1160.93","1884.08","89","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1278.84","53","","5253.92","5253.92","5253.92","1 through 10","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1399.48","58","","12181.47","12181.47","12181.47","1 through 10","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1508.06","62.5","","1350.68","1350.68","1350.68","1 through 10","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1072.53","44.45","","1910.74","891.94","1910.74","1 through 10","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","WELLPOINT [1015]","HB CH WELLPOINT","1879.89","77.91","","1829.79","1561.50","2617.12","88","1072.53","1879.89","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2412.90","1809.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1430.85","59.3","","1359.46","1201.30","1689.00","61","1206.45","1892.92","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2412.90","1809.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1430.85","59.3","","1718.92","1718.92","1718.92","1 through 10","1206.45","1892.92","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2412.90","1809.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1892.92","78.45","","1910.74","1019.06","2344.84","74","1206.45","1892.92","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 50/64 OR3O DUAL MOBILITY","SUP-ITM-10280246","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","AETNA [1001]","HB CH AETNA HMO / PPO","1340.61","58.3","","1530.90","1160.93","1884.08","89","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.74","53","","5253.92","5253.92","5253.92","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1333.71","58","","12181.47","12181.47","12181.47","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1437.19","62.5","","1350.68","1350.68","1350.68","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1022.13","44.45","","1910.74","891.94","1910.74","1 through 10","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","WELLPOINT [1015]","HB CH WELLPOINT","1791.54","77.91","","1829.79","1561.50","2617.12","88","1022.13","1791.54","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1359.46","1201.30","1689.00","61","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1718.92","1718.92","1718.92","1 through 10","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.96","78.45","","1910.74","1019.06","2344.84","74","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","AETNA [1001]","HB CH AETNA HMO / PPO","1652.81","58.3","","1530.90","1160.93","1884.08","89","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1502.55","53","","5253.92","5253.92","5253.92","1 through 10","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1644.30","58","","12181.47","12181.47","12181.47","1 through 10","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1771.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1260.16","44.45","","1910.74","891.94","1910.74","1 through 10","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB CH WELLPOINT","2208.75","77.91","","1829.79","1561.50","2617.12","88","1260.16","2208.75","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1681.16","59.3","","1359.46","1201.30","1689.00","61","1417.5","2224.06","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1681.16","59.3","","1718.92","1718.92","1718.92","1 through 10","1417.5","2224.06","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2224.06","78.45","","1910.74","1019.06","2344.84","74","1417.5","2224.06","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1530.90","1160.93","1884.08","89","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","5253.92","5253.92","5253.92","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","12181.47","12181.47","12181.47","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","1350.68","1350.68","1350.68","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1910.74","891.94","1910.74","1 through 10","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1829.79","1561.50","2617.12","88","933.45","1636.11","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1359.46","1201.30","1689.00","61","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1718.92","1718.92","1718.92","1 through 10","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL 52MM IMPLANT SIZE E SHE TRIDENT HEMISPHERICAL CLUSTER ULTRA HIGH 06","SUP-ITM-10019899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1910.74","1019.06","2344.84","74","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","1138.60","58.3","","1530.90","1160.93","1884.08","89","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1035.09","53","","5253.92","5253.92","5253.92","1 through 10","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1132.74","58","","12181.47","12181.47","12181.47","1 through 10","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1220.63","62.5","","1350.68","1350.68","1350.68","1 through 10","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","868.11","44.45","","1910.74","891.94","1910.74","1 through 10","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","WELLPOINT [1015]","HB CH WELLPOINT","1521.58","77.91","","1829.79","1561.50","2617.12","88","868.11","1521.58","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1359.46","1201.30","1689.00","61","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1718.92","1718.92","1718.92","1 through 10","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1532.13","78.45","","1910.74","1019.06","2344.84","74","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 54MM SIZE 4 TRINITY I CLUSTER TAPER","SUP-ITM-10197313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","AETNA [1001]","HB CH AETNA HMO / PPO","1195.53","58.3","","1530.90","1160.93","1884.08","89","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.84","53","","5253.92","5253.92","5253.92","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1189.38","58","","12181.47","12181.47","12181.47","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1281.66","62.5","","1350.68","1350.68","1350.68","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.51","44.45","","1910.74","891.94","1910.74","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","WELLPOINT [1015]","HB CH WELLPOINT","1597.66","77.91","","1829.79","1561.50","2617.12","88","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1216.04","59.3","","1359.46","1201.30","1689.00","61","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1216.04","59.3","","1718.92","1718.92","1718.92","1 through 10","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1608.73","78.45","","1910.74","1019.06","2344.84","74","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","AETNA [1001]","HB CH AETNA HMO / PPO","1195.53","58.3","","1530.90","1160.93","1884.08","89","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.84","53","","5253.92","5253.92","5253.92","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1189.38","58","","12181.47","12181.47","12181.47","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1281.66","62.5","","1350.68","1350.68","1350.68","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.51","44.45","","1910.74","891.94","1910.74","1 through 10","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","WELLPOINT [1015]","HB CH WELLPOINT","1597.66","77.91","","1829.79","1561.50","2617.12","88","911.51","1597.66","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1216.04","59.3","","1359.46","1201.30","1689.00","61","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1216.04","59.3","","1718.92","1718.92","1718.92","1 through 10","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1608.73","78.45","","1910.74","1019.06","2344.84","74","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1530.90","1160.93","1884.08","89","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","5253.92","5253.92","5253.92","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2110.19","58","","12181.47","12181.47","12181.47","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2273.91","62.5","","1350.68","1350.68","1350.68","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1617.20","44.45","","1910.74","891.94","1910.74","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","1829.79","1561.50","2617.12","88","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1359.46","1201.30","1689.00","61","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1718.92","1718.92","1718.92","1 through 10","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 64MM HOLE REVISION G7 OSSEOTI MULTI","SUP-ITM-10201589","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","1910.74","1019.06","2344.84","74","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1530.90","1160.93","1884.08","89","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","5253.92","5253.92","5253.92","1 through 10","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","12181.47","12181.47","12181.47","1 through 10","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1910.74","891.94","1910.74","1 through 10","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","1829.79","1561.50","2617.12","88","1466.85","2571.03","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1359.46","1201.30","1689.00","61","1650","2588.85","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1718.92","1718.92","1718.92","1 through 10","1650","2588.85","percent of total billed charges",""
"ACETABULAR SHELL 64MM REDAPT MODULAR","SUP-ITM-10280263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1910.74","1019.06","2344.84","74","1650","2588.85","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1530.90","1160.93","1884.08","89","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","5253.92","5253.92","5253.92","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2110.19","58","","12181.47","12181.47","12181.47","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2273.91","62.5","","1350.68","1350.68","1350.68","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1617.20","44.45","","1910.74","891.94","1910.74","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","1829.79","1561.50","2617.12","88","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1359.46","1201.30","1689.00","61","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1718.92","1718.92","1718.92","1 through 10","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 66MM TRABECULAR METAL REVISION POROUS TANTALUM TIVANIUM","SUP-ITM-10011133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","1910.74","1019.06","2344.84","74","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL SZ 58D 3 HOLE LOGICAL-G SERIES","SUP-ITM-10304241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1530.90","1160.93","1884.08","89","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","5253.92","5253.92","5253.92","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2110.19","58","","12181.47","12181.47","12181.47","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2273.91","62.5","","1350.68","1350.68","1350.68","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1617.20","44.45","","1910.74","891.94","1910.74","1 through 10","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","1829.79","1561.50","2617.12","88","1617.2","2834.56","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1359.46","1201.30","1689.00","61","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1718.92","1718.92","1718.92","1 through 10","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","1910.74","1019.06","2344.84","74","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","1530.90","1160.93","1884.08","89","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","5253.92","5253.92","5253.92","1 through 10","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","12181.47","12181.47","12181.47","1 through 10","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1910.74","891.94","1910.74","1 through 10","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","1829.79","1561.50","2617.12","88","133.35","233.73","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","1359.46","1201.30","1689.00","61","150","235.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","1718.92","1718.92","1718.92","1 through 10","150","235.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1910.74","1019.06","2344.84","74","150","235.35","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","82.00","61.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.63","59.3","","46.88","46.88","46.88","1 through 10","8.44","64.33","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","64.33","78.45","","80.00","80.00","80.00","1 through 10","8.44","64.33","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","157.00","117.75","AETNA [1001]","HB CH AETNA HMO / PPO","91.53","58.3","","86.75","86.75","86.75","1 through 10","18.03","149.31","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.10","59.3","","89.66","89.66","89.66","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","90.59","57.7","","176.41","92.26","176.41","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","94.99","60.5","","96.85","96.85","96.85","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","69.71","69.71","69.71","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","69.71","69.71","69.71","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","46.02","46.02","46.02","1 through 10","29.93","81.59","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1159.00","869.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","598.61","1771","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1159.00","869.25","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","630.12","1 through 10","598.61","1771","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1159.00","869.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","617.52","617.52","1 through 10","598.61","1771","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1159.00","869.25","WELLPOINT [1015]","HB CH WELLPOINT","902.98","77.91","","887.63","887.63","887.63","1 through 10","598.61","1771","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","outpatient","","","1159.00","869.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","687.29","59.3","","660.42","660.42","660.42","1 through 10","515.18","1293.36","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","outpatient","","","1159.00","869.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","909.24","78.45","","866.44","866.44","866.44","1 through 10","515.18","1293.36","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2676.00","2007.00","AETNA [1001]","HB CH AETNA HMO / PPO","1560.11","58.3","","1475.33","1475.33","1475.33","1 through 10","598.61","2084.87","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2676.00","2007.00","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","1890.36","1 through 10","598.61","2084.87","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2676.00","2007.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.92","617.92","617.92","1 through 10","598.61","2084.87","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2676.00","2007.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","573.29","573.29","573.29","1 through 10","598.61","2084.87","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","2676.00","2007.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2099.32","78.45","","2000.42","2000.42","2000.42","1 through 10","751.79","2099.32","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","949.00","711.75","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","739.62","12","351.32","981.49","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","369.81","369.81","369.81","1 through 10","351.32","981.49","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","949.00","711.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","562.76","59.3","","540.88","540.88","540.88","1 through 10","416.64","744.49","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","744.49","78.45","","709.60","709.60","709.60","1 through 10","416.64","744.49","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","AETNA [1001]","HB CH AETNA HMO / PPO","220.37","58.3","","209.79","209.79","209.79","1 through 10","162.16","294.5","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","219.24","58","","99.16","99.16","99.16","1 through 10","162.16","294.5","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","236.25","62.5","","109.28","106.11","109.28","1 through 10","162.16","294.5","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","WELLPOINT [1015]","HB CH WELLPOINT","294.50","77.91","","134.12","134.12","134.12","1 through 10","162.16","294.5","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","185.48","49.07","","99.45","99.45","99.45","1 through 10","151.2","296.54","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.38","50.1","","99.45","99.45","99.45","1 through 10","151.2","296.54","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","224.15","59.3","","216.82","216.82","216.82","1 through 10","151.2","296.54","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","296.54","78.45","","284.46","284.46","284.46","1 through 10","151.2","296.54","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","107.74","12","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","70.66","72.1","","71.63","71.63","71.63","1 through 10","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","62.13","63.4","","62.99","62.99","62.99","1 through 10","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","WELLPOINT [1015]","HB CH WELLPOINT","76.35","77.91","","74.82","74.82","74.82","1 through 10","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","14","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","56.55","57.7","","57.29","57.29","109.54","23","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","60.14","60.14","71.63","1 through 10","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","68.88","68.88","68.88","1 through 10","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","43.28","73.04","1 through 10","29.02","76.88","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","125.00","93.75","AETNA [1001]","HB CH AETNA HMO / PPO","72.88","58.3","","69.17","69.17","69.17","1 through 10","15.01","118.75","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","125.00","93.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.13","59.3","","71.49","71.49","71.49","1 through 10","14.72","98.06","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.06","78.45","","93.79","55.58","93.79","1 through 10","14.72","98.06","percent of total billed charges",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","30994.07","23245.55","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11457.85","11457.85","11457.85","1 through 10","1247.17","9479.5954","case rate",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","30994.07","23245.55","MEDICARE [2001]","HB NWH MEDICARE","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9165.49","9149.05","24271.87","14","1247.17","9479.5954","other","Inpatient Psych"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","","","","inpatient","","","50615.17","37961.38","MEDICARE [2001]","HB NWH MEDICARE","14788.45","","Case rate ($14,788.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,191.76, add-ons for qualifying new technology services are included. If operating cost exceeds $60,334.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,072.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $13,658.34. The transfer operating threshold is the transfer adjustment factor * $15,191.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.12. The transfer capital threshold is the transfer adjustment factor * $1,130.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15048.29","15048.29","15048.29","1 through 10","14492.68","15591.9863","other","Inpatient Replacement Plans DRG"
"Acute And Subacute Endocarditis With McC","288","MS-DRG","","","","","","","","inpatient","","","50946.82","38210.11","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","22977.38","","Case rate ($23,446.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,085.73, add-ons for qualifying new technology services are included. If operating cost exceeds $69,228.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,733.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $21,654.57. The transfer operating threshold is the transfer adjustment factor * $24,085.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,791.74. The transfer capital threshold is the transfer adjustment factor * $1,791.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15732.18","15732.18","15732.18","1 through 10","22977.38","27011.8035","other","Inpatient DRG"
"Acute And Subacute Endocarditis With McC","288","MS-DRG","","","","","","","","inpatient","","","50946.82","38210.11","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","22977.38","","Case rate ($23,446.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,085.73, add-ons for qualifying new technology services are included. If operating cost exceeds $69,228.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,733.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $21,654.57. The transfer operating threshold is the transfer adjustment factor * $24,085.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,791.74. The transfer capital threshold is the transfer adjustment factor * $1,791.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18917.20","18917.20","18917.20","1 through 10","22977.38","27011.8035","other","Inpatient DRG"
"Acute And Subacute Endocarditis,MAJOR","193","DRG","","","","","","","","inpatient","","","24013.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","21634.9482","","Per diem ($4,294). If length of stay < 12, first 1 days paid at a per diem of $8,588 instead.","21634.9482","21472.68","21472.68","1 through 10","1979","37918.33","per diem","Estimated amount calculated based on 2 day length of stay."
"Acute And Subacute Endocarditis,MODERATE","193","DRG","","","","","","","","inpatient","","","50615.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26650.26","","Standard inlier is a Case rate ($26,650.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,783.11) for the length of stay and the standard reimbursement.","15132.43","15132.43","15132.43","1 through 10","1979","37918.33","case rate",""
"Acute Anxiety And Stress Syndromes,MINOR","756","DRG","","","","","","","","inpatient","","","32152.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","5014.51","","Fee schedule rate ($5,014.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","746.53","746.53","746.53","1 through 10","954.59","37187.48","case rate",""
"Acute Bronchitis And Related Symptoms,EXTREME","145","DRG","","","","","","","","inpatient","","","37678.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30123.46","","Standard inlier is a Case rate ($30,123.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,417, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,275.90) for the length of stay and the standard reimbursement.","30123.46","30123.46","30123.46","1 through 10","4778.52","33972.84","case rate",""
"Acute Bronchitis And Related Symptoms,MAJOR","145","DRG","","","","","","","","inpatient","","","19148.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19774.20","","Standard inlier is a Case rate ($19,774.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,532, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,806.86) for the length of stay and the standard reimbursement.","18875.37","18875.37","18875.37","1 through 10","4778.52","33972.84","case rate",""
"Acute Bronchitis And Related Symptoms,MAJOR","145","DRG","","","","","","","","inpatient","","","19148.62","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","7304.29","","Case rate ($7,869.22). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,299.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8191.26","8191.26","8191.26","1 through 10","4778.52","33972.84","case rate",""
"Acute Bronchitis And Related Symptoms,MODERATE","145","DRG","","","","","","","","inpatient","","","14853.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14267.73","","Standard inlier is a Case rate ($14,267.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,025.36) for the length of stay and the standard reimbursement.","14267.73","14267.73","14267.73","1 through 10","4778.52","33972.84","case rate",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","399.00","299.25","AETNA [1001]","HB CH AETNA HMO / PPO","232.62","58.3","","220.00","220.00","233.04","1 through 10","46.68","379.05","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","399.00","299.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.61","59.3","","227.37","227.37","524.46","11","46.39","313.02","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","298.29","176.77","315.98","1 through 10","46.39","313.02","percent of total billed charges",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","48748.20","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45154.91","","Standard inlier is a Case rate ($45,154.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,409.55) for the length of stay and the standard reimbursement.","45154.90","45154.90","45154.90","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","48748.20","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","21839.75","","Case rate ($23,528.89). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $65,958.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23589.39","23589.39","23589.39","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","29372.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24135.11","","Standard inlier is a Case rate ($24,135.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,425.88) for the length of stay and the standard reimbursement.","23038.06","2792.57","24135.11","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","29372.72","","MASSHEALTH [3001]","HB NWH MEDICAID","9656.42","","Case rate ($10,403.27). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,833.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,068.24 and the sum of the standard inlier and any outlier amount.","10430.02","10430.02","10430.02","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","29372.72","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9656.42","","Case rate ($10,403.27). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,833.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,068.24 and the sum of the standard inlier and any outlier amount.","10430.02","325.64","10430.02","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MINOR","469","DRG","","","","","","","","inpatient","","","11432.34","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5623.16","","Fee schedule rate ($5,623.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5623.16","5623.16","5623.16","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21291.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14395.21","","Standard inlier is a Case rate ($14,395.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,043.46) for the length of stay and the standard reimbursement.","14395.20","14395.20","14395.20","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21291.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15463.32","","Standard inlier is a Case rate ($15,463.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,194.95) for the length of stay and the standard reimbursement.","15463.32","15463.32","15463.32","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21291.30","","MASSHEALTH [3001]","HB NWH MEDICAID","5403.39","","Case rate ($5,821.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,251.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2720.89","2720.89","2720.89","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21291.30","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5403.39","","Case rate ($5,821.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,251.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5836.27","5836.27","5836.27","1 through 10","4097.67","48189.51","case rate",""
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","102732.91","77049.68","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","46612.81","","Case rate ($47,564.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $48,861.23, add-ons for qualifying new technology services are included. If operating cost exceeds $94,003.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,576.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $43,929.29. The transfer operating threshold is the transfer adjustment factor * $48,861.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,634.80. The transfer capital threshold is the transfer adjustment factor * $3,634.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","47156.08","47156.08","47156.08","1 through 10","46612.81","54659.4697","other","Inpatient DRG"
"Acute Major Eye Infections With Cc/McC","121","MS-DRG","","","","","","","","inpatient","","","16503.91","12377.93","MEDICARE [2001]","HB NWH MEDICARE","10078.75","","Case rate ($10,078.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,353.61, add-ons for qualifying new technology services are included. If operating cost exceeds $55,495.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,712.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,308.54. The transfer operating threshold is the transfer adjustment factor * $10,353.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $770.21. The transfer capital threshold is the transfer adjustment factor * $770.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11101.78","11101.78","11101.78","1 through 10","9877.18","11502.8848","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8201.91","","Case rate ($7,963.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,354.49. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6884.90","6884.90","6884.90","1 through 10","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8755.54","","Case rate ($8,755.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,147.01. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6623.89","6623.89","6623.89","1 through 10","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","MEDICARE [2001]","HB NWH MEDICARE","8755.54","","Case rate ($8,755.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,147.01. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8797.83","1142.68","8813.65","24","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7803.76","","Case rate ($7,963.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,354.49. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6555.52","6555.02","7863.37","1 through 10","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","7803.76","","Case rate ($7,963.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,354.49. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8944.05","8944.05","8944.05","1 through 10","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","20655.64","15491.73","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7803.76","","Case rate ($7,963.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,180.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,322.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,354.49. The transfer operating threshold is the transfer adjustment factor * $8,180.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.53. The transfer capital threshold is the transfer adjustment factor * $608.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7873.76","7873.76","7873.76","1 through 10","7803.76","9115.6802","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","43464.03","32598.02","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14314.74","","Case rate ($13,897.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,276.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,419.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,835.75. The transfer operating threshold is the transfer adjustment factor * $14,276.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.06. The transfer capital threshold is the transfer adjustment factor * $1,062.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14730.33","14730.33","14730.33","1 through 10","13619.85","16466.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","43464.03","32598.02","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15280.99","","Case rate ($15,280.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,276.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,419.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,218.93. The transfer operating threshold is the transfer adjustment factor * $14,276.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.06. The transfer capital threshold is the transfer adjustment factor * $1,062.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15442.87","15442.87","15442.87","1 through 10","13619.85","16466.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","43464.03","32598.02","MEDICARE [2001]","HB NWH MEDICARE","15280.99","","Case rate ($15,280.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,276.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,419.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,218.93. The transfer operating threshold is the transfer adjustment factor * $14,276.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.06. The transfer capital threshold is the transfer adjustment factor * $1,062.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15665.79","11462.52","15693.97","76","13619.85","16466.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","43464.03","32598.02","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13619.85","","Case rate ($13,897.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,276.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,419.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,835.75. The transfer operating threshold is the transfer adjustment factor * $14,276.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.06. The transfer capital threshold is the transfer adjustment factor * $1,062.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14022.93","13649.77","15782.36","1 through 10","13619.85","16466.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","43464.03","32598.02","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13619.85","","Case rate ($13,897.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,276.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,419.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,835.75. The transfer operating threshold is the transfer adjustment factor * $14,276.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.06. The transfer capital threshold is the transfer adjustment factor * $1,062.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13995.42","6826.97","14030.67","12","13619.85","16466.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","17191.55","12893.66","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6264.89","","Case rate ($6,264.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,435.74, add-ons for qualifying new technology services are included. If operating cost exceeds $51,578.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,420.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,786.13. The transfer operating threshold is the transfer adjustment factor * $6,435.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.76. The transfer capital threshold is the transfer adjustment factor * $478.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6254.76","6254.76","6821.99","1 through 10","6139.59","7170.5139","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","17191.55","12893.66","MEDICARE [2001]","HB NWH MEDICARE","6264.89","","Case rate ($6,264.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,435.74, add-ons for qualifying new technology services are included. If operating cost exceeds $51,578.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,420.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,786.13. The transfer operating threshold is the transfer adjustment factor * $6,435.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.76. The transfer capital threshold is the transfer adjustment factor * $478.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6932.92","6932.92","6932.92","1 through 10","6139.59","7170.5139","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","17191.55","12893.66","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6139.59","","Case rate ($6,264.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,435.74, add-ons for qualifying new technology services are included. If operating cost exceeds $51,578.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,420.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,786.13. The transfer operating threshold is the transfer adjustment factor * $6,435.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.76. The transfer capital threshold is the transfer adjustment factor * $478.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6182.57","6182.57","6182.57","1 through 10","6139.59","7170.5139","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","47493.85","35620.39","MEDICARE [2001]","HB NWH MEDICARE","18869.50","","Case rate ($18,869.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,629.53, add-ons for qualifying new technology services are included. If operating cost exceeds $62,771.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,253.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $17,558.04. The transfer operating threshold is the transfer adjustment factor * $17,629.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.46. The transfer capital threshold is the transfer adjustment factor * $1,311.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18696.22","18696.22","18696.22","1 through 10","16818.27","19336.9506","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","47493.85","35620.39","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16818.27","","Case rate ($17,161.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,629.53, add-ons for qualifying new technology services are included. If operating cost exceeds $62,771.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,253.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $15,850.04. The transfer operating threshold is the transfer adjustment factor * $17,629.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.46. The transfer capital threshold is the transfer adjustment factor * $1,311.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16667.70","16667.70","16667.70","1 through 10","16818.27","19336.9506","other","Inpatient DRG"
"Acute Myocardial Infarction,EXTREME","190","DRG","","","","","","","","inpatient","","","28440.08","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","43151.79","","Fee schedule rate ($43,151.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43151.79","43151.79","43151.79","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18614.24","","Standard inlier is a Case rate ($18,614.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,745, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,642.36) for the length of stay and the standard reimbursement.","2642.36","2642.36","2642.36","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19995.41","","Standard inlier is a Case rate ($19,995.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,745, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,838.26) for the length of stay and the standard reimbursement.","19995.40","19995.40","19995.40","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16675.1886","","Fee schedule rate ($16,675.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16675.1886","6670.08","6670.08","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17508.8627","","Fee schedule rate ($17,508.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17508.8627","7337.01","7337.01","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","MASSHEALTH [3001]","HB NWH MEDICAID","4532.91","","Case rate ($4,883.49). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,313.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1371.44","1371.44","1371.44","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","17191.55","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","17397.87","","Fee schedule rate ($17,397.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16891.29","16891.29","16891.29","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","15382.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20293.52","","Standard inlier is a Case rate ($20,293.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,467, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,880.74) for the length of stay and the standard reimbursement.","5499.90","5499.90","5499.90","1 through 10","2586","52054.71","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","15382.62","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16675.1886","","Per diem ($4,185). If length of stay < 5, first 1 days paid at a per diem of $8,370 instead.","16675.1886","20923.62","20923.62","1 through 10","2586","52054.71","per diem","Estimated amount calculated based on 1 day length of stay."
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","both","","","113.00","84.75","AETNA [1001]","HB CH AETNA HMO / PPO","65.88","58.3","","124.74","124.74","124.74","1 through 10","16.53","107.35","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.65","78.45","","50.12","50.12","50.12","1 through 10","11.02","88.65","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB CH AETNA HMO / PPO","125.35","58.3","","121.91","121.91","121.91","1 through 10","18.27","204.25","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","215.00","161.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","127.50","59.3","","125.99","125.99","125.99","1 through 10","14.12","168.67","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","168.67","78.45","","165.29","97.95","215.00","1 through 10","14.12","168.67","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","121.91","121.91","121.91","1 through 10","18.27","632.7","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","666.00","499.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","394.94","59.3","","125.99","125.99","125.99","1 through 10","14.12","522.48","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","165.29","97.95","215.00","1 through 10","14.12","522.48","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","1530.90","1160.93","1884.08","89","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","5253.92","5253.92","5253.92","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","408.90","58","","12181.47","12181.47","12181.47","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","440.63","62.5","","1350.68","1350.68","1350.68","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.37","44.45","","1910.74","891.94","1910.74","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","1829.79","1561.50","2617.12","88","313.37","549.27","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","1359.46","1201.30","1689.00","61","352.5","553.07","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","418.07","59.3","","1718.92","1718.92","1718.92","1 through 10","352.5","553.07","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","1910.74","1019.06","2344.84","74","352.5","553.07","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","AETNA [1001]","HB CH AETNA HMO / PPO","1173.58","58.3","","1530.90","1160.93","1884.08","89","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1066.89","53","","5253.92","5253.92","5253.92","1 through 10","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1167.54","58","","12181.47","12181.47","12181.47","1 through 10","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1258.13","62.5","","1350.68","1350.68","1350.68","1 through 10","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","894.78","44.45","","1910.74","891.94","1910.74","1 through 10","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","WELLPOINT [1015]","HB CH WELLPOINT","1568.33","77.91","","1829.79","1561.50","2617.12","88","894.78","1568.33","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2013.00","1509.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1193.71","59.3","","1359.46","1201.30","1689.00","61","1006.5","1579.2","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2013.00","1509.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1193.71","59.3","","1718.92","1718.92","1718.92","1 through 10","1006.5","1579.2","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2013.00","1509.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1579.20","78.45","","1910.74","1019.06","2344.84","74","1006.5","1579.2","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","AETNA [1001]","HB CH AETNA HMO / PPO","297.33","58.3","","1530.90","1160.93","1884.08","89","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","270.30","53","","5253.92","5253.92","5253.92","1 through 10","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","295.80","58","","12181.47","12181.47","12181.47","1 through 10","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","318.75","62.5","","1350.68","1350.68","1350.68","1 through 10","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","1910.74","891.94","1910.74","1 through 10","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","both","","","510.00","382.50","WELLPOINT [1015]","HB CH WELLPOINT","397.34","77.91","","1829.79","1561.50","2617.12","88","226.7","397.34","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.43","59.3","","1359.46","1201.30","1689.00","61","255","400.1","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","302.43","59.3","","1718.92","1718.92","1718.92","1 through 10","255","400.1","percent of total billed charges",""
"ADAPTER HEAD 7.00MM FEMORAL ENDOPROSTHETIC VERSYS ZIMALOY PLUS HIP 14","SUP-ITM-10014672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","1910.74","1019.06","2344.84","74","255","400.1","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","AETNA [1001]","HB CH AETNA HMO / PPO","205.68","58.3","","1530.90","1160.93","1884.08","89","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.98","53","","5253.92","5253.92","5253.92","1 through 10","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","204.62","58","","12181.47","12181.47","12181.47","1 through 10","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","220.50","62.5","","1350.68","1350.68","1350.68","1 through 10","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.82","44.45","","1910.74","891.94","1910.74","1 through 10","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","WELLPOINT [1015]","HB CH WELLPOINT","274.87","77.91","","1829.79","1561.50","2617.12","88","156.82","274.87","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","209.21","59.3","","1359.46","1201.30","1689.00","61","176.4","276.77","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","209.21","59.3","","1718.92","1718.92","1718.92","1 through 10","176.4","276.77","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.77","78.45","","1910.74","1019.06","2344.84","74","176.4","276.77","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","1530.90","1160.93","1884.08","89","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","5253.92","5253.92","5253.92","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","408.90","58","","12181.47","12181.47","12181.47","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","440.63","62.5","","1350.68","1350.68","1350.68","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.37","44.45","","1910.74","891.94","1910.74","1 through 10","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","1829.79","1561.50","2617.12","88","313.37","549.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","1359.46","1201.30","1689.00","61","352.5","553.07","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","418.07","59.3","","1718.92","1718.92","1718.92","1 through 10","352.5","553.07","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","1910.74","1019.06","2344.84","74","352.5","553.07","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Adjustment Disorders,MAJOR","755","DRG","","","","","","","","inpatient","","","25309.00","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","12560.11","","Fee schedule rate ($12,560.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","55869.00","55869.00","55869.00","1 through 10","886.93","18840.17","case rate",""
"Adjustment Disorders,MINOR","755","DRG","","","","","","","","inpatient","","","23520.57","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","11717.63","","Fee schedule rate ($11,717.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8845.00","8845.00","8845.00","1 through 10","886.93","18840.17","case rate",""
"Adjustment Gastric Band, via Port Injection/Aspiration","PX-76002982","CDM","43999","CPT","0761","RC","","","","outpatient","","","255.00","191.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","127.76","50.1","","248.00","248.00","248.00","1 through 10","109.4","1873.9","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","14.16","147.35","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","14.16","147.35","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","14.16","147.35","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","14.16","147.35","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","1 through 10","14.67","178.12","percent of total billed charges",""
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","1 through 10","14.67","178.12","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","14.67","178.12","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","51.85","155.55","21","14.67","178.12","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","23","14.67","178.12","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.82","53.70","17","14.67","178.12","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.27","14.58","24.27","1 through 10","16.5","100.34","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","1 through 10","14.67","178.12","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","1 through 10","14.67","178.12","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","14.67","178.12","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","51.85","155.55","21","14.67","178.12","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","23","14.67","178.12","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.82","53.70","17","14.67","178.12","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.27","14.58","24.27","1 through 10","16.5","100.34","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","1 through 10","14.67","147.35","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","51.85","155.55","21","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","23","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.82","53.70","17","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.27","14.58","24.27","1 through 10","16.5","100.34","percent of total billed charges",""
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.81","54.79","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","1 through 10","17.49","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.81","54.79","1 through 10","17.49","147.35","other","OPPS APC"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","48425.13","36318.85","MEDICARE [2001]","HB NWH MEDICARE","20879.54","","Case rate ($20,879.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,507.47, add-ons for qualifying new technology services are included. If operating cost exceeds $64,649.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,393.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $19,428.37. The transfer operating threshold is the transfer adjustment factor * $19,507.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.17. The transfer capital threshold is the transfer adjustment factor * $1,451.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21750.88","21750.88","21750.88","1 through 10","18609.81","22498.83","other","Inpatient DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","48425.13","36318.85","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","18609.81","","Case rate ($18,989.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,507.47, add-ons for qualifying new technology services are included. If operating cost exceeds $64,649.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,393.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $17,538.43. The transfer operating threshold is the transfer adjustment factor * $19,507.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.17. The transfer capital threshold is the transfer adjustment factor * $1,451.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19432.75","19432.75","19432.75","1 through 10","18609.81","22498.83","other","Inpatient DRG"
"Adrenal And Pituitary Procedures Without Cc/McC","615","MS-DRG","","","","","","","","inpatient","","","42740.21","32055.16","MEDICARE [2001]","HB NWH MEDICARE","13330.01","","Case rate ($13,330.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,454.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,596.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,868.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,403.56. The transfer operating threshold is the transfer adjustment factor * $12,454.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.46. The transfer capital threshold is the transfer adjustment factor * $926.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13701.38","13701.38","13701.38","1 through 10","11880.96","14170.937","other","Inpatient DRG"
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","70228.75","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","34524.78","","Fee schedule rate ($34,524.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34524.78","34524.78","34524.78","1 through 10","11189.47","40849.92","case rate",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","326.00","244.50","AETNA [1001]","HB CH AETNA HMO / PPO","190.06","58.3","","179.74","179.74","179.74","12","37.85","309.7","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","326.00","244.50","TRICARE [160005]","HB NWH TRICARE","309.70","95","","46.54","46.54","46.54","1 through 10","37.85","309.7","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","326.00","244.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.32","59.3","","185.76","185.76","235.26","1 through 10","39.83","255.75","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","255.75","78.45","","243.71","144.43","243.71","11","39.83","255.75","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB CH AETNA HMO / PPO","130.01","58.3","","123.04","123.04","123.04","1 through 10","67.25","745.32","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","outpatient","","","223.00","167.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","127.16","1 through 10","111.5","473.25","percent of total billed charges",""
"Aftercare With Cc/McC","949","MS-DRG","","","","","","","","inpatient","","","10820.62","8115.46","MEDICARE [2001]","HB NWH MEDICARE","11333.33","","Case rate ($11,333.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,588.57, add-ons for qualifying new technology services are included. If operating cost exceeds $55,730.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,729.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,545.64. The transfer operating threshold is the transfer adjustment factor * $10,588.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.69. The transfer capital threshold is the transfer adjustment factor * $787.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10298.16","10298.16","10298.16","1 through 10","10101.33","11333.33","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","21734.17","16300.63","MEDICARE [2001]","HB NWH MEDICARE","9756.44","","Case rate ($9,756.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,022.52, add-ons for qualifying new technology services are included. If operating cost exceeds $55,164.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,687.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,010.87. The transfer operating threshold is the transfer adjustment factor * $10,022.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.58. The transfer capital threshold is the transfer adjustment factor * $745.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10867.80","8827.57","10887.47","1 through 10","9561.31","11260.6043","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","21734.17","16300.63","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9561.31","","Case rate ($9,756.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,022.52, add-ons for qualifying new technology services are included. If operating cost exceeds $55,164.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,687.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,010.87. The transfer operating threshold is the transfer adjustment factor * $10,022.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $745.58. The transfer capital threshold is the transfer adjustment factor * $745.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9728.05","9728.05","9728.05","1 through 10","9561.31","11260.6043","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","34659.68","25994.76","MEDICARE [2001]","HB NWH MEDICARE","17765.42","","Case rate ($17,765.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,597.99, add-ons for qualifying new technology services are included. If operating cost exceeds $61,740.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,176.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,530.69. The transfer operating threshold is the transfer adjustment factor * $16,597.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.73. The transfer capital threshold is the transfer adjustment factor * $1,234.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17716.85","17716.85","17748.71","1 through 10","15834.21","18356.9507","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","34659.68","25994.76","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15834.21","","Case rate ($16,157.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,597.99, add-ons for qualifying new technology services are included. If operating cost exceeds $61,740.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,176.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,922.63. The transfer operating threshold is the transfer adjustment factor * $16,597.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.73. The transfer capital threshold is the transfer adjustment factor * $1,234.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15826.75","15826.75","15826.75","1 through 10","15834.21","18356.9507","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/McC","561","MS-DRG","","","","","","","","inpatient","","","19955.57","14966.68","MEDICARE [2001]","HB NWH MEDICARE","6964.92","","Case rate ($6,964.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,154.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,297.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,474.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,432.68. The transfer operating threshold is the transfer adjustment factor * $7,154.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.25. The transfer capital threshold is the transfer adjustment factor * $532.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","701.03","701.03","701.03","1 through 10","6825.62","8085.2464","other","Inpatient Replacement Plans DRG"
"AGENT BULKING ADULT IMPLANT UROLOGICAL MACROPLASTIQUE INJECTABLE FEMALE IMPLANTABLE TREATING STRESS URINARY INCONTINENCE","SUP-ITM-10076828","CDM","L8606","HCPCS","0278","RC","","","","both","","","3057.00","2292.75","AETNA [1001]","HB CH AETNA HMO / PPO","1782.23","58.3","","1786.05","1786.05","1786.05","1 through 10","747.41","2381.71","percent of total billed charges",""
"AGENT BULKING ADULT IMPLANT UROLOGICAL MACROPLASTIQUE INJECTABLE FEMALE IMPLANTABLE TREATING STRESS URINARY INCONTINENCE","SUP-ITM-10076828","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","3057.00","2292.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1812.80","59.3","","1845.90","1845.90","1845.90","1 through 10","1358.84","2398.22","percent of total billed charges",""
"AGENT BULKING ADULT IMPLANT UROLOGICAL MACROPLASTIQUE INJECTABLE FEMALE IMPLANTABLE TREATING STRESS URINARY INCONTINENCE","SUP-ITM-10076828","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","3057.00","2292.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2398.22","78.45","","2421.72","2421.72","2421.72","1 through 10","1358.84","2398.22","percent of total billed charges",""
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","29.48","29.48","29.48","1 through 10","7.62","50.35","percent of total billed charges",""
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","outpatient","","","53.00","39.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","41.58","78.45","","39.98","39.98","39.98","1 through 10","5.34","41.58","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","48","4.85","39.9","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","30.66","73","","29.93","29.93","29.93","1 through 10","4.85","39.9","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","TRICARE [160005]","HB NWH TRICARE","39.90","95","","5.96","5.96","5.96","1 through 10","4.85","39.9","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.67","44.45","","18.68","18.68","18.68","1 through 10","4.85","39.9","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","72.09","44","5.11","32.95","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","18.68","31.52","36","5.11","32.95","percent of total billed charges",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","22534.62","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","8005.33","","Fee schedule rate ($8,005.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8005.27","8005.27","8005.27","1 through 10","954.59","105986.03","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","22534.62","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9417.97","","Fee schedule rate ($9,417.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9417.97","9417.97","9417.97","1 through 10","954.59","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","16649.62","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12296.59","","Fee schedule rate ($12,296.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12296.59","12296.59","12296.59","1 through 10","954.59","105986.03","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Age >21 Without McC","898","TRIS-DRG","","","","","","","","inpatient","","","21174.22","","TRICARE [160005]","HB NWH TRICARE","5537.11","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,763.36). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $51,584.80 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,848.42), capped at $7,000.32. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $51,584.80 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","10716.13","10716.13","10716.13","1 through 10","5537.11","5537.11","other","Inpatient DRGs"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1212.53","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15992.73","15992.73","15992.73","1 through 10","1154.79","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6660.51","6660.51","10843.06","1 through 10","1154.79","17913.45","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","MEDICARE [2001]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16996.28","10622.66","17026.83","14","1154.79","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15183.21","15183.21","15183.21","1 through 10","1154.79","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","17508.05","17288.50","23142.38","1 through 10","1154.79","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","27827.03","20870.27","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","19295.73","19295.73","19295.73","1 through 10","1154.79","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1151.90","","Case rate ($1,097.05) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7927.90","7927.90","7927.90","1 through 10","1097.05","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6660.51","6660.51","6660.51","1 through 10","1097.05","9061.94","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","HUMANA [1012]","HB NWH MEDICARE","1097.05","","Case rate ($1,097.05) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","4546.84","4546.84","4546.84","1 through 10","1097.05","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","MEDICARE [2001]","HB NWH MEDICARE","1097.05","","Case rate ($1,097.05) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8419.87","978.30","8435.01","29","1097.05","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","1097.05","","Case rate ($1,097.05) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8565.98","837.67","8639.20","16","1097.05","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18128.96","13596.72","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1097.05","","Case rate ($1,097.05) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7673.17","7673.17","7673.17","1 through 10","1097.05","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","15165.63","11374.22","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","993.12","","Case rate ($993.12) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","5327.29","5321.40","5328.90","1 through 10","993.12","6171.7249","other","Inpatient Psych"
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","75107.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11607.948","","Fee schedule rate ($70,482.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11607.948","70482.14","70482.14","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","75107.50","","MASSHEALTH [3001]","HB NWH MEDICAID","25078.36","","Case rate ($27,017.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,447.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27087.46","27087.46","27087.46","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","75107.50","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","25078.36","","Case rate ($27,017.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,447.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","75107.50","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","25078.36","","Case rate ($27,017.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,447.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27087.46","27087.46","27087.46","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24157.08","","Standard inlier is a Case rate ($24,157.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,429.19) for the length of stay and the standard reimbursement.","24769.99","24769.99","24769.99","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25949.52","","Standard inlier is a Case rate ($25,949.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,683.43) for the length of stay and the standard reimbursement.","14733.70","3633.00","25949.52","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11607.948","","Per diem ($3,592). If length of stay < 7, first 1 days paid at a per diem of $7,184 instead.","11607.948","25146.64","25146.64","1 through 10","3772","116294.43","per diem","Estimated amount calculated based on 5 day length of stay."
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12188.286","","Per diem ($3,772). If length of stay < 7, first 1 days paid at a per diem of $7,544 instead.","12188.286","98066.00","98066.00","1 through 10","3772","116294.43","per diem","Estimated amount calculated based on 5 day length of stay."
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","MASSHEALTH [3001]","HB NWH MEDICAID","11172.34","","Case rate ($12,036.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,466.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,848.91 and the sum of the standard inlier and any outlier amount.","12067.39","9895.00","12067.39","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10959.12","","Fee schedule rate ($10,959.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10959.12","10959.12","10959.12","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23358.83","","Fee schedule rate ($23,358.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23358.83","23358.83","23358.83","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","11172.34","","Case rate ($12,036.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,466.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,848.91 and the sum of the standard inlier and any outlier amount.","12067.39","2734.67","12067.39","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","40221.50","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","11172.34","","Case rate ($12,036.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,466.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,848.91 and the sum of the standard inlier and any outlier amount.","12067.39","349.14","12067.39","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MINOR","280","DRG","","","","","","","","inpatient","","","16164.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13206.50","","Standard inlier is a Case rate ($13,206.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,260, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,874.61) for the length of stay and the standard reimbursement.","12606.20","12606.20","12606.20","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","14180.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17040.73","","Standard inlier is a Case rate ($17,040.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,923, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,418.86) for the length of stay and the standard reimbursement.","16266.15","16266.15","16266.15","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","14180.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11607.948","","Fee schedule rate ($14,842.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11607.948","14270.24","14270.24","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","14180.02","","MASSHEALTH [3001]","HB NWH MEDICAID","6285.30","","Case rate ($6,771.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,201.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,040.16 and the sum of the standard inlier and any outlier amount.","896.78","896.78","896.78","1 through 10","3772","116294.43","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","14180.02","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6285.30","","Case rate ($6,771.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,201.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,040.16 and the sum of the standard inlier and any outlier amount.","6788.83","6788.83","6788.83","1 through 10","3772","116294.43","case rate",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.06","58.3","","43.66","43.66","43.66","1 through 10","9.52","75.05","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","79.00","59.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.85","59.3","","45.12","45.12","45.12","1 through 10","10.01","61.98","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.98","78.45","","59.20","59.20","59.20","1 through 10","10.01","61.98","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","188.24","188.24","188.24","1 through 10","39.94","323.95","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","341.00","255.75","TRICARE [160005]","HB NWH TRICARE","323.95","95","","49.10","49.10","49.10","1 through 10","39.94","323.95","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","194.55","194.55","248.20","1 through 10","42.03","267.51","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","255.24","255.24","332.00","13","42.03","267.51","percent of total billed charges",""
"Aldosterone Suppression Panel","PX-30000043","CDM","80408","CPT","0300","RC","","","","outpatient","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","754.70","49.07","","381.80","381.80","381.80","1 through 10","615.2","1206.56","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","90.00","67.50","AETNA [1001]","HB CH AETNA HMO / PPO","52.47","58.3","","49.90","49.90","249.48","20","17.57","105.83","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","90.00","67.50","WELLPOINT [1015]","HB CH WELLPOINT","70.12","77.91","","421.31","69.31","421.31","1 through 10","17.57","105.83","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.01","44.45","","40.09","40.09","40.09","1 through 10","32.94","70.61","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","473.58","40.09","608.89","1 through 10","32.94","70.61","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","462","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","TRICARE [160005]","HB NWH TRICARE","58.90","95","","6.29","6.29","6.29","12","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","26","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","105.48","382","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","27.34","46.13","324","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","462","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","TRICARE [160005]","HB NWH TRICARE","58.90","95","","6.29","6.29","6.29","12","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","26","5.12","58.9","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","105.48","382","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","27.34","46.13","324","5.39","48.64","percent of total billed charges",""
"Allergic Reactions With McC","915","MS-DRG","","","","","","","","inpatient","","","28400.36","21300.27","MEDICARE [2001]","HB NWH MEDICARE","14569.26","","Case rate ($14,569.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,966.58, add-ons for qualifying new technology services are included. If operating cost exceeds $60,108.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,055.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,455.89. The transfer operating threshold is the transfer adjustment factor * $14,966.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,113.37. The transfer capital threshold is the transfer adjustment factor * $1,113.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16586.61","16586.61","16586.61","1 through 10","14277.87","17261.62","other","Inpatient Replacement Plans DRG"
"Allergic Reactions Without McC","916","MS-DRG","","","","","","","","inpatient","","","18926.83","14195.12","MEDICARE [2001]","HB NWH MEDICARE","5772.78","","Case rate ($5,772.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,930.21, add-ons for qualifying new technology services are included. If operating cost exceeds $51,072.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,383.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,331.62. The transfer operating threshold is the transfer adjustment factor * $5,930.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.15. The transfer capital threshold is the transfer adjustment factor * $441.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1415.24","1415.24","1415.24","1 through 10","5657.32","6567.2849","other","Inpatient Replacement Plans DRG"
"Allergic Reactions Without McC","916","MS-DRG","","","","","","","","inpatient","","","18926.83","14195.12","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","5657.32","","Case rate ($5,772.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,930.21, add-ons for qualifying new technology services are included. If operating cost exceeds $51,072.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,383.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,331.62. The transfer operating threshold is the transfer adjustment factor * $5,930.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $441.15. The transfer capital threshold is the transfer adjustment factor * $441.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6411.31","6411.31","6411.31","1 through 10","5657.32","6567.2849","other","Inpatient DRG"
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","27690.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23547.86","","Standard inlier is a Case rate ($23,547.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,137, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,342.52) for the length of stay and the standard reimbursement.","22477.50","22477.50","22477.50","1 through 10","3177.59","79184.82","case rate",""
"Allergic Reactions,MINOR","811","DRG","","","","","","","","inpatient","","","16897.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","7663.39","","Standard inlier is a Case rate ($7,663.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $19,510, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,087.85) for the length of stay and the standard reimbursement.","7663.38","7663.38","7663.38","1 through 10","3177.59","79184.82","case rate",""
"Allergic Reactions,MINOR","811","DRG","","","","","","","","inpatient","","","16897.18","","MASSHEALTH [3001]","HB NWH MEDICAID","3345.99","","Case rate ($3,604.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,034.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4517.56","4517.56","4517.56","1 through 10","3177.59","79184.82","case rate",""
"Allergic Reactions,MINOR","811","DRG","","","","","","","","inpatient","","","16897.18","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","3345.99","","Case rate ($3,604.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,034.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","3177.59","79184.82","case rate",""
"Allergic Reactions,MODERATE","811","DRG","","","","","","","","inpatient","","","20797.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12245.31","","Standard inlier is a Case rate ($12,245.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,738.17) for the length of stay and the standard reimbursement.","11688.70","11688.70","11688.70","1 through 10","3177.59","79184.82","case rate",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","AETNA [1001]","HB CH AETNA HMO / PPO","556.18","58.3","","52.60","33.42","52.60","1932","96.52","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","WELLPOINT [1015]","HB CH WELLPOINT","743.26","77.91","","77.77","77.77","77.77","240","96.52","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","954.00","715.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","497.99","52.2","","47.77","47.77","47.77","480","477","497.99","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","AETNA [1001]","HB CH AETNA HMO / PPO","3993.98","58.3","","52.60","33.42","52.60","1932","96.52","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","WELLPOINT [1015]","HB CH WELLPOINT","5337.40","77.91","","77.77","77.77","77.77","240","96.52","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6850.73","5138.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","3576.08","52.2","","47.77","47.77","47.77","480","3425.37","3576.08","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","AETNA [1001]","HB CH AETNA HMO / PPO","4220.92","58.3","","52.60","33.42","52.60","1932","96.52","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","WELLPOINT [1015]","HB CH WELLPOINT","5640.68","77.91","","77.77","77.77","77.77","240","96.52","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7240.00","5430.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3779.28","52.2","","47.77","47.77","47.77","480","3620","3779.28","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","AETNA [1001]","HB CH AETNA HMO / PPO","5003.31","58.3","","52.60","33.42","52.60","1932","96.52","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","WELLPOINT [1015]","HB CH WELLPOINT","6686.24","77.91","","77.77","77.77","77.77","240","96.52","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","8582.00","6436.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4479.80","52.2","","47.77","47.77","47.77","480","4291","4479.8","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","AETNA [1001]","HB CH AETNA HMO / PPO","5697.08","58.3","","52.60","33.42","52.60","1932","96.52","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","WELLPOINT [1015]","HB CH WELLPOINT","7613.37","77.91","","77.77","77.77","77.77","240","96.52","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9772.00","7329.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5100.98","52.2","","47.77","47.77","47.77","480","4886","5100.98","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","AETNA [1001]","HB CH AETNA HMO / PPO","241.36","58.3","","52.60","33.42","52.60","1932","96.52","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","WELLPOINT [1015]","HB CH WELLPOINT","322.55","77.91","","77.77","77.77","77.77","240","96.52","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","414.00","310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","216.11","52.2","","47.77","47.77","47.77","480","207","216.11","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","AETNA [1001]","HB CH AETNA HMO / PPO","998.68","58.3","","52.60","33.42","52.60","1932","96.52","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","WELLPOINT [1015]","HB CH WELLPOINT","1334.60","77.91","","77.77","77.77","77.77","240","96.52","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1713.00","1284.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","894.19","52.2","","47.77","47.77","47.77","480","856.5","894.19","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","AETNA [1001]","HB CH AETNA HMO / PPO","739.62","58.3","","52.60","33.42","52.60","1932","96.52","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","WELLPOINT [1015]","HB CH WELLPOINT","988.41","77.91","","77.77","77.77","77.77","240","96.52","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1268.65","951.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.24","52.2","","47.77","47.77","47.77","480","634.33","662.24","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","AETNA [1001]","HB CH AETNA HMO / PPO","33.74","58.3","","52.60","33.42","52.60","1932","30.67","106.36","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","WELLPOINT [1015]","HB CH WELLPOINT","45.09","77.91","","77.77","77.77","77.77","240","30.67","106.36","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","57.87","43.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.21","52.2","","47.77","47.77","47.77","480","28.94","30.21","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","AETNA [1001]","HB CH AETNA HMO / PPO","404.02","58.3","","52.60","33.42","52.60","1932","96.52","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","WELLPOINT [1015]","HB CH WELLPOINT","539.92","77.91","","77.77","77.77","77.77","240","96.52","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","693.00","519.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","361.75","52.2","","47.77","47.77","47.77","480","346.5","361.75","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","AETNA [1001]","HB CH AETNA HMO / PPO","1173.58","58.3","","52.60","33.42","52.60","1932","96.52","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","WELLPOINT [1015]","HB CH WELLPOINT","1568.33","77.91","","77.77","77.77","77.77","240","96.52","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2013.00","1509.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1050.79","52.2","","47.77","47.77","47.77","480","1006.5","1050.79","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","52.60","33.42","52.60","1932","96.52","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","77.77","77.77","77.77","240","96.52","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","634.23","52.2","","47.77","47.77","47.77","480","607.5","634.23","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","AETNA [1001]","HB CH AETNA HMO / PPO","2011.35","58.3","","52.60","33.42","52.60","1932","96.52","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","WELLPOINT [1015]","HB CH WELLPOINT","2687.90","77.91","","77.77","77.77","77.77","240","96.52","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3450.00","2587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1800.90","52.2","","47.77","47.77","47.77","480","1725","1800.9","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","AETNA [1001]","HB CH AETNA HMO / PPO","2489.41","58.3","","52.60","33.42","52.60","1932","96.52","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","WELLPOINT [1015]","HB CH WELLPOINT","3326.76","77.91","","77.77","77.77","77.77","240","96.52","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4270.00","3202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2228.94","52.2","","47.77","47.77","47.77","480","2135","2228.94","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","AETNA [1001]","HB CH AETNA HMO / PPO","2231.72","58.3","","52.60","33.42","52.60","1932","96.52","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","WELLPOINT [1015]","HB CH WELLPOINT","2982.39","77.91","","77.77","77.77","77.77","240","96.52","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3828.00","2871.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1998.22","52.2","","47.77","47.77","47.77","480","1914","1998.22","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","AETNA [1001]","HB CH AETNA HMO / PPO","2596.68","58.3","","52.60","33.42","52.60","1932","96.52","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","WELLPOINT [1015]","HB CH WELLPOINT","3470.11","77.91","","77.77","77.77","77.77","240","96.52","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4454.00","3340.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2324.99","52.2","","47.77","47.77","47.77","480","2227","2324.99","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","438.42","58.3","","52.60","33.42","52.60","1932","96.52","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","WELLPOINT [1015]","HB CH WELLPOINT","585.88","77.91","","77.77","77.77","77.77","240","96.52","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","752.00","564.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","392.54","52.2","","47.77","47.77","47.77","480","376","392.54","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","AETNA [1001]","HB CH AETNA HMO / PPO","3264.80","58.3","","52.60","33.42","52.60","1932","96.52","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","WELLPOINT [1015]","HB CH WELLPOINT","4362.96","77.91","","77.77","77.77","77.77","240","96.52","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5600.00","4200.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2923.20","52.2","","47.77","47.77","47.77","480","2800","2923.2","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","AETNA [1001]","HB CH AETNA HMO / PPO","241.19","58.3","","464.71","67.87","1012.10","221","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","241.19","58.3","","293.04","293.04","293.04","11","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","219.26","53","","983.89","983.89","983.89","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","239.95","58","","677.18","677.18","677.18","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","258.56","62.5","","46.58","46.58","46.58","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","302.00","73","","747.15","747.15","747.15","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.89","44.45","","1141.67","481.21","1141.67","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.89","44.45","","76.54","76.54","76.54","1 through 10","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.70","310.27","WELLPOINT [1015]","HB CH WELLPOINT","322.31","77.91","","273.64","94.28","1367.51","138","183.89","322.31","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.70","310.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","245.32","59.3","","720.78","230.14","2010.94","427","206.85","324.55","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.70","310.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","245.32","59.3","","344.45","344.45","344.45","1 through 10","206.85","324.55","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.70","310.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","324.55","78.45","","1120.13","1120.13","1120.13","1 through 10","206.85","324.55","percent of total billed charges",""
"ALLOGRAFT BONE 5CC .1 TO 2MM CHIP CANCELLOUS","SUP-ITM-10277011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.70","310.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.55","78.45","","456.17","105.33","1284.66","242","206.85","324.55","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","AETNA [1001]","HB CH AETNA HMO / PPO","4453.37","58.3","","2190.90","412.50","9264.59","16","3395.41","5951.32","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4430.45","58","","1903.20","1903.20","3826.66","1 through 10","3395.41","5951.32","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4774.19","62.5","","2186.25","2186.25","2186.25","32","3395.41","5951.32","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5576.26","73","","5556.60","5556.60","5556.60","1 through 10","3395.41","5951.32","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","WELLPOINT [1015]","HB CH WELLPOINT","5951.32","77.91","","1955.15","885.83","3150.40","26","3395.41","5951.32","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7638.71","5729.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","4529.76","59.3","","831.03","253.22","2394.88","18","3819.36","5992.57","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7638.71","5729.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5992.57","78.45","","2481.69","1563.74","8149.28","1 through 10","3819.36","5992.57","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","both","","","19393.66","14545.24","AETNA [1001]","HB CH AETNA HMO / PPO","11306.50","58.3","","2190.90","412.50","9264.59","16","8620.48","15109.6","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","both","","","19393.66","14545.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11248.32","58","","1903.20","1903.20","3826.66","1 through 10","8620.48","15109.6","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","both","","","19393.66","14545.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12121.04","62.5","","2186.25","2186.25","2186.25","32","8620.48","15109.6","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","both","","","19393.66","14545.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","14157.37","73","","5556.60","5556.60","5556.60","1 through 10","8620.48","15109.6","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","both","","","19393.66","14545.24","WELLPOINT [1015]","HB CH WELLPOINT","15109.60","77.91","","1955.15","885.83","3150.40","26","8620.48","15109.6","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19393.66","14545.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","11500.44","59.3","","831.03","253.22","2394.88","18","9696.83","15214.33","percent of total billed charges",""
"ALLOGRAFT OSTEOARTICULAR GROWTH PLATE","SUP-ITM-10232049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19393.66","14545.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","15214.33","78.45","","2481.69","1563.74","8149.28","1 through 10","9696.83","15214.33","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","AETNA [1001]","HB CH AETNA HMO / PPO","886.58","58.3","","2190.90","412.50","9264.59","16","675.96","1184.79","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","882.02","58","","1903.20","1903.20","3826.66","1 through 10","675.96","1184.79","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","950.45","62.5","","2186.25","2186.25","2186.25","32","675.96","1184.79","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1110.13","73","","5556.60","5556.60","5556.60","1 through 10","675.96","1184.79","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","WELLPOINT [1015]","HB CH WELLPOINT","1184.79","77.91","","1955.15","885.83","3150.40","26","675.96","1184.79","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1520.72","1140.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.79","59.3","","831.03","253.22","2394.88","18","760.36","1193","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1520.72","1140.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1193.00","78.45","","2481.69","1563.74","8149.28","1 through 10","760.36","1193","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","AETNA [1001]","HB CH AETNA HMO / PPO","2046.09","58.3","","2190.90","412.50","9264.59","16","1560.01","2734.32","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2035.56","58","","1903.20","1903.20","3826.66","1 through 10","1560.01","2734.32","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2193.49","62.5","","2186.25","2186.25","2186.25","32","1560.01","2734.32","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.00","73","","5556.60","5556.60","5556.60","1 through 10","1560.01","2734.32","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","WELLPOINT [1015]","HB CH WELLPOINT","2734.32","77.91","","1955.15","885.83","3150.40","26","1560.01","2734.32","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3509.59","2632.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.19","59.3","","831.03","253.22","2394.88","18","1754.8","2753.27","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3509.59","2632.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.27","78.45","","2481.69","1563.74","8149.28","1 through 10","1754.8","2753.27","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","AETNA [1001]","HB CH AETNA HMO / PPO","2770.82","58.3","","2190.90","412.50","9264.59","16","2112.58","3702.83","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2756.57","58","","1903.20","1903.20","3826.66","1 through 10","2112.58","3702.83","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2970.44","62.5","","2186.25","2186.25","2186.25","32","2112.58","3702.83","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3469.47","73","","5556.60","5556.60","5556.60","1 through 10","2112.58","3702.83","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","WELLPOINT [1015]","HB CH WELLPOINT","3702.83","77.91","","1955.15","885.83","3150.40","26","2112.58","3702.83","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4752.70","3564.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","2818.35","59.3","","831.03","253.22","2394.88","18","2376.35","3728.49","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4752.70","3564.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3728.49","78.45","","2481.69","1563.74","8149.28","1 through 10","2376.35","3728.49","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","AETNA [1001]","HB CH AETNA HMO / PPO","5584.71","58.3","","2190.90","412.50","9264.59","16","4257.99","7463.21","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5555.98","58","","1903.20","1903.20","3826.66","1 through 10","4257.99","7463.21","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5987.04","62.5","","2186.25","2186.25","2186.25","32","4257.99","7463.21","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6992.87","73","","5556.60","5556.60","5556.60","1 through 10","4257.99","7463.21","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","WELLPOINT [1015]","HB CH WELLPOINT","7463.21","77.91","","1955.15","885.83","3150.40","26","4257.99","7463.21","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9579.27","7184.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","5680.51","59.3","","831.03","253.22","2394.88","18","4789.64","7514.94","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9579.27","7184.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7514.94","78.45","","2481.69","1563.74","8149.28","1 through 10","4789.64","7514.94","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","130.00","21","16.43","131.1","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","20","17.3","108.26","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","138.00","103.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","1 through 10","17.3","108.26","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","17.3","108.26","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","131.54","65.77","131.54","1 through 10","14.17","113.05","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","67.98","67.98","1 through 10","14.92","93.36","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","89.18","89.18","89.18","1 through 10","14.92","93.36","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","123.60","11","13.17","106.4","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","49.66","49.66","49.66","1 through 10","13.17","106.4","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","13","13.86","87.86","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","64.47","83.80","1 through 10","13.86","87.86","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","196","5.19","41.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","CHAMPVA [160001]","HB NWH TRICARE","41.80","95","","6.39","6.39","6.39","1 through 10","5.19","41.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32.12","73","","24.38","24.38","24.38","1 through 10","5.19","41.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","TRICARE [160005]","HB NWH TRICARE","41.80","95","","6.39","6.07","49.39","1 through 10","5.19","41.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","33.06","33.06","33.06","1 through 10","5.19","41.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","164","5.46","34.52","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","19.59","33.06","165","5.46","34.52","percent of total billed charges",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","46568.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21090.25","","Standard inlier is a Case rate ($21,090.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,993.84) for the length of stay and the standard reimbursement.","20131.88","20131.88","20131.88","1 through 10","4103.38","71004.51","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","46568.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22655.14","","Standard inlier is a Case rate ($22,655.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,215.80) for the length of stay and the standard reimbursement.","22655.14","22655.14","22655.14","1 through 10","4103.38","71004.51","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","46568.56","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8907.03","","Case rate ($9,595.92). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,025.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12025.74","12025.74","12025.74","1 through 10","4103.38","71004.51","case rate",""
"Alteration In Consciousness,MODERATE","052","DRG","","","","","","","","inpatient","","","9584.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17427.84","","Standard inlier is a Case rate ($17,427.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,293, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,473.81) for the length of stay and the standard reimbursement.","16636.73","16636.73","16636.73","1 through 10","4103.38","71004.51","case rate",""
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB CH AETNA HMO / PPO","54.80","58.3","","103.20","51.60","103.20","1 through 10","16.53","99.51","percent of total billed charges",""
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","outpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.74","59.3","","53.33","45.50","53.33","1 through 10","11.02","73.74","percent of total billed charges",""
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","41.46","69.96","1 through 10","11.02","73.74","percent of total billed charges",""
"Amino Acids Qn Single","PX-30000300","CDM","82131","CPT","0301","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","111.40","78.45","","106.09","106.09","106.09","1 through 10","17.39","111.4","percent of total billed charges",""
"Aminolevulinic Acid (Ala)","PX-30000301","CDM","82135","CPT","0301","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","1 through 10","16.12","181.45","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","68.61","1 through 10","14.28","117.8","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","1 through 10","15.03","97.28","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1240.00","930.00","AETNA [1001]","HB CH AETNA HMO / PPO","722.92","58.3","","683.80","683.80","683.80","1 through 10","558.04","1064.97","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1240.00","930.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","873.64","873.64","873.64","1 through 10","558.04","1064.97","other","Multiple Surgery"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1240.00","930.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","558.04","1064.97","per diem",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1240.00","930.00","WELLPOINT [1015]","HB CH WELLPOINT","966.08","77.91","","949.85","949.85","949.85","1 through 10","558.04","1064.97","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","902.34","902.34","921.49","1 through 10","551.18","972.78","other","ASC "
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1355.43","903.62","1384.14","14","551.18","972.78","other","ASC "
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","735.32","59.3","","2242.63","706.72","2242.63","1 through 10","551.18","972.78","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1378.36","1378.36","1378.36","1 through 10","551.18","972.78","other","Multiple Surgery"
"Ampicillin","PX-30001480","CDM","80299","CPT","0300","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","159.6","percent of total billed charges",""
"Ampicillin","PX-30001480","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","125.99","125.99","125.99","1 through 10","14.12","131.8","percent of total billed charges",""
"Ampicillin","PX-30001480","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","165.29","97.95","215.00","1 through 10","14.12","131.8","percent of total billed charges",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","62601.52","46951.14","MEDICARE [2001]","HB NWH MEDICARE","24696.51","","Case rate ($24,696.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,370.03, add-ons for qualifying new technology services are included. If operating cost exceeds $70,512.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,829.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $22,809.24. The transfer operating threshold is the transfer adjustment factor * $25,370.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,887.28. The transfer capital threshold is the transfer adjustment factor * $1,887.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27794.52","15228.61","27844.49","1 through 10","24202.58","28798.7458","other","Inpatient Replacement Plans DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","125527.05","94145.29","MEDICARE [2001]","HB NWH MEDICARE","46885.11","","Case rate ($46,885.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,804.14, add-ons for qualifying new technology services are included. If operating cost exceeds $88,946.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,200.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $43,626.51. The transfer operating threshold is the transfer adjustment factor * $43,804.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,258.60. The transfer capital threshold is the transfer adjustment factor * $3,258.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48159.45","48159.45","48159.45","1 through 10","41788.42","50521.25","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","125527.05","94145.29","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","41788.42","","Case rate ($42,641.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,804.14, add-ons for qualifying new technology services are included. If operating cost exceeds $88,946.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,200.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $39,382.64. The transfer operating threshold is the transfer adjustment factor * $43,804.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,258.60. The transfer capital threshold is the transfer adjustment factor * $3,258.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42934.18","42934.18","42934.18","1 through 10","41788.42","50521.25","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC","241","MS-DRG","","","","","","","","inpatient","","","47511.71","35633.78","MEDICARE [2001]","HB NWH MEDICARE","13188.07","","Case rate ($13,188.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,321.45, add-ons for qualifying new technology services are included. If operating cost exceeds $57,463.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,858.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,271.48. The transfer operating threshold is the transfer adjustment factor * $12,321.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.60. The transfer capital threshold is the transfer adjustment factor * $916.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14436.64","14436.64","14436.64","1 through 10","11754.44","14210.87","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","","","","inpatient","","","45960.12","34470.09","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","21678.78","","Case rate ($21,678.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,254.19, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,448.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,172.07. The transfer operating threshold is the transfer adjustment factor * $20,254.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,506.71. The transfer capital threshold is the transfer adjustment factor * $1,506.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20296.61","20296.61","20296.61","1 through 10","19322.17","21678.78","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","","","","inpatient","","","45960.12","34470.09","MEDICARE [2001]","HB NWH MEDICARE","21678.78","","Case rate ($21,678.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,254.19, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,448.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,172.07. The transfer operating threshold is the transfer adjustment factor * $20,254.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,506.71. The transfer capital threshold is the transfer adjustment factor * $1,506.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20626.64","20626.64","20626.64","1 through 10","19322.17","21678.78","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With McC","474","MS-DRG","","","","","","","","inpatient","","","92869.39","69652.04","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","38309.17","","Case rate ($37,193.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $38,207.69, add-ons for qualifying new technology services are included. If operating cost exceeds $83,349.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,784.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $34,351.09. The transfer operating threshold is the transfer adjustment factor * $38,207.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,842.28. The transfer capital threshold is the transfer adjustment factor * $2,842.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","40186.01","40186.01","40186.01","1 through 10","36449.5","44066.62","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With McC","474","MS-DRG","","","","","","","","inpatient","","","92869.39","69652.04","MEDICARE [2001]","HB NWH MEDICARE","40895.04","","Case rate ($40,895.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $38,207.69, add-ons for qualifying new technology services are included. If operating cost exceeds $83,349.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,784.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $38,052.76. The transfer operating threshold is the transfer adjustment factor * $38,207.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,842.28. The transfer capital threshold is the transfer adjustment factor * $2,842.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42879.68","42879.68","42879.68","1 through 10","36449.5","44066.62","other","Inpatient DRG"
"Amputation Of Lower Limb Except Toes,EXTREME","305","DRG","","","","","","","","inpatient","","","99247.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","94245.47","","Standard inlier is a Case rate ($94,245.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $108,333, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,378.51) for the length of stay and the standard reimbursement.","94245.46","94245.46","94245.46","1 through 10","14157.34","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","71247.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","54535.08","","Standard inlier is a Case rate ($54,535.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $63,729, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,741.02) for the length of stay and the standard reimbursement.","54535.08","54535.08","54535.08","1 through 10","14157.34","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","71247.78","","MASSHEALTH [3001]","HB NWH MEDICAID","21903.73","","Case rate ($23,597.81). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $66,027.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,306.73 and the sum of the standard inlier and any outlier amount.","23658.49","23658.49","23658.49","1 through 10","14157.34","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","37188.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36006.48","","Standard inlier is a Case rate ($36,006.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,034, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,110.97) for the length of stay and the standard reimbursement.","30410.50","30410.50","30410.50","1 through 10","14157.34","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","37188.93","","MASSHEALTH [3001]","HB NWH MEDICAID","14157.34","","Case rate ($15,252.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,682.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15291.52","15291.52","15291.52","1 through 10","14157.34","215331.88","case rate",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","48826.28","36619.71","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","16690.27","","Case rate ($16,204.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,646.06, add-ons for qualifying new technology services are included. If operating cost exceeds $61,788.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,180.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $14,965.84. The transfer operating threshold is the transfer adjustment factor * $16,646.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,238.30. The transfer capital threshold is the transfer adjustment factor * $1,238.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17288.05","17288.05","17288.05","1 through 10","15880.07","19198.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","48826.28","36619.71","MEDICARE [2001]","HB NWH MEDICARE","17816.87","","Case rate ($17,816.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,646.06, add-ons for qualifying new technology services are included. If operating cost exceeds $61,788.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,180.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $16,578.55. The transfer operating threshold is the transfer adjustment factor * $16,646.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,238.30. The transfer capital threshold is the transfer adjustment factor * $1,238.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18435.51","16200.72","18468.65","1 through 10","15880.07","19198.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","48826.28","36619.71","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15880.07","","Case rate ($16,204.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,646.06, add-ons for qualifying new technology services are included. If operating cost exceeds $61,788.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,180.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $14,965.84. The transfer operating threshold is the transfer adjustment factor * $16,646.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,238.30. The transfer capital threshold is the transfer adjustment factor * $1,238.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16469.80","16469.80","16469.80","1 through 10","15880.07","19198.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","105734.54","79300.90","MEDICARE [2001]","HB NWH MEDICARE","30214.58","","Case rate ($30,214.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,038.57, add-ons for qualifying new technology services are included. If operating cost exceeds $76,180.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,250.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $27,905.61. The transfer operating threshold is the transfer adjustment factor * $31,038.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,308.97. The transfer capital threshold is the transfer adjustment factor * $2,308.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36888.21","36888.21","36888.21","1 through 10","29610.29","35798.16","other","Inpatient Replacement Plans DRG"
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","1 through 10","6.35","56.05","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","59.00","44.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.07","73","","32.32","32.32","32.32","1 through 10","6.35","56.05","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","59.00","44.25","TRICARE [160005]","HB NWH TRICARE","56.05","95","","7.42","7.42","7.42","1 through 10","6.35","56.05","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","59.00","44.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.99","59.3","","33.40","33.40","122.25","16","6.68","46.29","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","43.82","25.97","43.82","1 through 10","6.68","46.29","percent of total billed charges",""
"Anal And Perineal Procedures,MODERATE","226","DRG","","","","","","","","inpatient","","","25226.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26326.66","","Standard inlier is a Case rate ($26,326.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,656, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,737.17) for the length of stay and the standard reimbursement.","26326.65","26326.65","26326.65","1 through 10","7687.95","29520.51","case rate",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","","","","inpatient","","","31393.38","23545.03","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12467.90","","Case rate ($12,467.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,648.59, add-ons for qualifying new technology services are included. If operating cost exceeds $56,790.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,808.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,601.35. The transfer operating threshold is the transfer adjustment factor * $11,648.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.54. The transfer capital threshold is the transfer adjustment factor * $866.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10855.93","10855.93","10855.93","1 through 10","11112.56","13434.83","other","Inpatient DRG"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","","","","inpatient","","","31393.38","23545.03","MEDICARE [2001]","HB NWH MEDICARE","12467.90","","Case rate ($12,467.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,648.59, add-ons for qualifying new technology services are included. If operating cost exceeds $56,790.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,808.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,601.35. The transfer operating threshold is the transfer adjustment factor * $11,648.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $866.54. The transfer capital threshold is the transfer adjustment factor * $866.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12015.17","12015.17","12015.17","1 through 10","11112.56","13434.83","other","Inpatient DRG"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","775.00","581.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","737.03","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","775.00","581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","388.28","50.1","","2255.00","204.62","2255.00","1 through 10","344.49","607.99","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","775.00","581.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","607.99","78.45","","1733.64","1733.64","1733.64","1 through 10","344.49","607.99","percent of total billed charges",""
"Anal Sphincterotomy","PX-75000453","CDM","46080","CPT","0750","RC","","","","both","","","3708.00","2781.00","AETNA [1001]","HB CH AETNA HMO / PPO","2161.76","58.3","","3384.99","3384.99","3384.99","1 through 10","1590.73","2888.9","percent of total billed charges",""
"Anal Sphincterotomy","PX-75000453","CDM","46080","CPT","0750","RC","","","","both","","","3708.00","2781.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1590.73","2888.9","per diem",""
"Anal Sphincterotomy","PX-75000453","CDM","46080","CPT","0750","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1857.71","50.1","","3860.43","3780.34","3860.43","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","outpatient","","","2450.00","1837.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1452.85","59.3","","1395.85","1395.85","1395.85","1 through 10","1089.03","3920.8","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","257.00","192.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.40","59.3","","146.50","146.50","146.50","1 through 10","128.5","222.03","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","257.00","192.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","201.62","78.45","","192.20","113.90","192.20","1 through 10","128.5","222.03","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","242.41","78.45","","230.64","230.64","230.64","1 through 10","154.5","275.14","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","248.35","248.35","248.35","1 through 10","64.05","427.5","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","256.67","256.67","256.67","1 through 10","198.88","353.03","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","336.73","336.73","336.73","1 through 10","198.88","353.03","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","474.00","355.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","232.59","49.07","","278.80","278.80","278.80","1 through 10","94.53","371.85","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","474.00","355.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","237.47","50.1","","278.80","278.80","278.80","1 through 10","94.53","371.85","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","474.00","355.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","281.08","59.3","","270.15","270.15","270.15","1 through 10","94.53","371.85","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","371.85","78.45","","354.42","354.41","354.42","1 through 10","94.53","371.85","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","818.00","613.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","641.72","78.45","","611.20","611.20","611.20","1 through 10","218.84","641.72","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","AETNA [1001]","HB CH AETNA HMO / PPO","865.76","58.3","","464.71","67.87","1012.10","221","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","865.76","58.3","","293.04","293.04","293.04","11","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","787.05","53","","983.89","983.89","983.89","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","861.30","58","","677.18","677.18","677.18","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","928.13","62.5","","46.58","46.58","46.58","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1084.05","73","","747.15","747.15","747.15","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.08","44.45","","1141.67","481.21","1141.67","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.08","44.45","","76.54","76.54","76.54","1 through 10","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","WELLPOINT [1015]","HB CH WELLPOINT","1156.96","77.91","","273.64","94.28","1367.51","138","660.08","1156.96","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","880.61","59.3","","720.78","230.14","2010.94","427","742.5","1164.98","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","880.61","59.3","","344.45","344.45","344.45","1 through 10","742.5","1164.98","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1164.98","78.45","","1120.13","1120.13","1120.13","1 through 10","742.5","1164.98","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1164.98","78.45","","456.17","105.33","1284.66","242","742.5","1164.98","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","464.71","67.87","1012.10","221","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","293.04","293.04","293.04","11","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","983.89","983.89","983.89","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","677.18","677.18","677.18","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","46.58","46.58","46.58","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","747.15","747.15","747.15","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1141.67","481.21","1141.67","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","76.54","76.54","76.54","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","273.64","94.28","1367.51","138","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","720.78","230.14","2010.94","427","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","344.45","344.45","344.45","1 through 10","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1120.13","1120.13","1120.13","1 through 10","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","456.17","105.33","1284.66","242","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","464.71","67.87","1012.10","221","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","293.04","293.04","293.04","11","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","983.89","983.89","983.89","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","677.18","677.18","677.18","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","46.58","46.58","46.58","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","747.15","747.15","747.15","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1141.67","481.21","1141.67","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","76.54","76.54","76.54","1 through 10","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","273.64","94.28","1367.51","138","800.1","1402.38","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","720.78","230.14","2010.94","427","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","344.45","344.45","344.45","1 through 10","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1120.13","1120.13","1120.13","1 through 10","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","456.17","105.33","1284.66","242","900","1412.1","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","AETNA [1001]","HB CH AETNA HMO / PPO","7223.37","58.3","","1530.90","1160.93","1884.08","89","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6566.70","53","","5253.92","5253.92","5253.92","1 through 10","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7186.20","58","","12181.47","12181.47","12181.47","1 through 10","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7743.75","62.5","","1350.68","1350.68","1350.68","1 through 10","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5507.36","44.45","","1910.74","891.94","1910.74","1 through 10","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","both","","","12390.00","9292.50","WELLPOINT [1015]","HB CH WELLPOINT","9653.05","77.91","","1829.79","1561.50","2617.12","88","5507.36","9653.05","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12390.00","9292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7347.27","59.3","","1359.46","1201.30","1689.00","61","6195","9719.96","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12390.00","9292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7347.27","59.3","","1718.92","1718.92","1718.92","1 through 10","6195","9719.96","percent of total billed charges",""
"ANCHOR HUMERAL 28X19MM SHOULDER SIDUS STEM FREE UNCEMENTED","SUP-ITM-10239021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12390.00","9292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9719.96","78.45","","1910.74","1019.06","2344.84","74","6195","9719.96","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","AETNA [1001]","HB CH AETNA HMO / PPO","5188.70","58.3","","1530.90","1160.93","1884.08","89","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4717.00","53","","5253.92","5253.92","5253.92","1 through 10","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5162.00","58","","12181.47","12181.47","12181.47","1 through 10","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5562.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3956.05","44.45","","1910.74","891.94","1910.74","1 through 10","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","both","","","8900.00","6675.00","WELLPOINT [1015]","HB CH WELLPOINT","6933.99","77.91","","1829.79","1561.50","2617.12","88","3956.05","6933.99","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8900.00","6675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5277.70","59.3","","1359.46","1201.30","1689.00","61","4450","6982.05","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8900.00","6675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5277.70","59.3","","1718.92","1718.92","1718.92","1 through 10","4450","6982.05","percent of total billed charges",""
"ANCHOR OSTEOTOMY SIZE 1 IBALANCE PATELLOFEMORAL RIGHT","SUP-ITM-10135816","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8900.00","6675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6982.05","78.45","","1910.74","1019.06","2344.84","74","4450","6982.05","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","AETNA [1001]","HB CH AETNA HMO / PPO","717.09","58.3","","464.71","67.87","1012.10","221","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","717.09","58.3","","293.04","293.04","293.04","11","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","651.90","53","","983.89","983.89","983.89","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","713.40","58","","677.18","677.18","677.18","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","768.75","62.5","","46.58","46.58","46.58","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","897.90","73","","747.15","747.15","747.15","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","546.74","44.45","","1141.67","481.21","1141.67","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","546.74","44.45","","76.54","76.54","76.54","1 through 10","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","WELLPOINT [1015]","HB CH WELLPOINT","958.29","77.91","","273.64","94.28","1367.51","138","546.74","958.29","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","729.39","59.3","","720.78","230.14","2010.94","427","615","964.94","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","729.39","59.3","","344.45","344.45","344.45","1 through 10","615","964.94","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","964.94","78.45","","1120.13","1120.13","1120.13","1 through 10","615","964.94","percent of total billed charges",""
"ANCHOR SOFT SP 2.6 FIBERTAK TRIPLE LOADED W/1.3MM SUTURE TAPE WHT/BLU BLK/WHT SELF-PUNCHING BX/5EA","SUP-ITM-10317755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","964.94","78.45","","456.17","105.33","1284.66","242","615","964.94","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","AETNA [1001]","HB CH AETNA HMO / PPO","500.21","58.3","","464.71","67.87","1012.10","221","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","500.21","58.3","","293.04","293.04","293.04","11","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","454.74","53","","983.89","983.89","983.89","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","497.64","58","","677.18","677.18","677.18","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","536.25","62.5","","46.58","46.58","46.58","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","626.34","73","","747.15","747.15","747.15","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.38","44.45","","1141.67","481.21","1141.67","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.38","44.45","","76.54","76.54","76.54","1 through 10","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","both","","","858.00","643.50","WELLPOINT [1015]","HB CH WELLPOINT","668.47","77.91","","273.64","94.28","1367.51","138","381.38","668.47","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","858.00","643.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","508.79","59.3","","720.78","230.14","2010.94","427","429","673.1","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","858.00","643.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","508.79","59.3","","344.45","344.45","344.45","1 through 10","429","673.1","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","858.00","643.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","673.10","78.45","","1120.13","1120.13","1120.13","1 through 10","429","673.1","percent of total billed charges",""
"ANCHOR SURGICAL 3MM GRYPHON PROKNOT SUTURE","SUP-ITM-10148433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","858.00","643.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","673.10","78.45","","456.17","105.33","1284.66","242","429","673.1","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","AETNA [1001]","HB CH AETNA HMO / PPO","599.91","58.3","","464.71","67.87","1012.10","221","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","599.91","58.3","","293.04","293.04","293.04","11","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","545.37","53","","983.89","983.89","983.89","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","596.82","58","","677.18","677.18","677.18","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","643.13","62.5","","46.58","46.58","46.58","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","747.15","747.15","747.15","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","1141.67","481.21","1141.67","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","76.54","76.54","76.54","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB CH WELLPOINT","801.69","77.91","","273.64","94.28","1367.51","138","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","610.20","59.3","","720.78","230.14","2010.94","427","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","610.20","59.3","","344.45","344.45","344.45","1 through 10","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","1120.13","1120.13","1120.13","1 through 10","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE 1 SIZE MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE RB","SUP-ITM-10030990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","456.17","105.33","1284.66","242","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","AETNA [1001]","HB CH AETNA HMO / PPO","1080.62","58.3","","464.71","67.87","1012.10","221","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1080.62","58.3","","293.04","293.04","293.04","11","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","982.38","53","","983.89","983.89","983.89","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1075.06","58","","677.18","677.18","677.18","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1158.47","62.5","","46.58","46.58","46.58","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1353.09","73","","747.15","747.15","747.15","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.90","44.45","","1141.67","481.21","1141.67","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.90","44.45","","76.54","76.54","76.54","1 through 10","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1853.55","1390.16","WELLPOINT [1015]","HB CH WELLPOINT","1444.10","77.91","","273.64","94.28","1367.51","138","823.9","1444.1","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1853.55","1390.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","1099.16","59.3","","720.78","230.14","2010.94","427","926.78","1454.11","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1853.55","1390.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1099.16","59.3","","344.45","344.45","344.45","1 through 10","926.78","1454.11","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1853.55","1390.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1454.11","78.45","","1120.13","1120.13","1120.13","1 through 10","926.78","1454.11","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1853.55","1390.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1454.11","78.45","","456.17","105.33","1284.66","242","926.78","1454.11","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","AETNA [1001]","HB CH AETNA HMO / PPO","784.92","58.3","","464.71","67.87","1012.10","221","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","784.92","58.3","","293.04","293.04","293.04","11","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","713.56","53","","983.89","983.89","983.89","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","780.88","58","","677.18","677.18","677.18","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","841.46","62.5","","46.58","46.58","46.58","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","982.83","73","","747.15","747.15","747.15","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","598.45","44.45","","1141.67","481.21","1141.67","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","598.45","44.45","","76.54","76.54","76.54","1 through 10","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.34","1009.75","WELLPOINT [1015]","HB CH WELLPOINT","1048.93","77.91","","273.64","94.28","1367.51","138","598.45","1048.93","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.34","1009.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","798.38","59.3","","720.78","230.14","2010.94","427","673.17","1056.2","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.34","1009.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","798.38","59.3","","344.45","344.45","344.45","1 through 10","673.17","1056.2","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.34","1009.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1056.20","78.45","","1120.13","1120.13","1120.13","1 through 10","673.17","1056.2","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.34","1009.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1056.20","78.45","","456.17","105.33","1284.66","242","673.17","1056.2","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","AETNA [1001]","HB CH AETNA HMO / PPO","695.52","58.3","","464.71","67.87","1012.10","221","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","695.52","58.3","","293.04","293.04","293.04","11","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","632.30","53","","983.89","983.89","983.89","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","691.95","58","","677.18","677.18","677.18","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","745.63","62.5","","46.58","46.58","46.58","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","870.90","73","","747.15","747.15","747.15","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","530.29","44.45","","1141.67","481.21","1141.67","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","530.29","44.45","","76.54","76.54","76.54","1 through 10","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.01","894.76","WELLPOINT [1015]","HB CH WELLPOINT","929.47","77.91","","273.64","94.28","1367.51","138","530.29","929.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.01","894.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","707.45","59.3","","720.78","230.14","2010.94","427","596.51","935.92","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.01","894.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","707.45","59.3","","344.45","344.45","344.45","1 through 10","596.51","935.92","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.01","894.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","935.92","78.45","","1120.13","1120.13","1120.13","1 through 10","596.51","935.92","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM NANOTACK 1.4MM INSERTER","SUP-ITM-10113396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.01","894.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","935.92","78.45","","456.17","105.33","1284.66","242","596.51","935.92","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","AETNA [1001]","HB CH AETNA HMO / PPO","769.56","58.3","","464.71","67.87","1012.10","221","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","769.56","58.3","","293.04","293.04","293.04","11","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","699.60","53","","983.89","983.89","983.89","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","765.60","58","","677.18","677.18","677.18","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","825.00","62.5","","46.58","46.58","46.58","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","963.60","73","","747.15","747.15","747.15","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.74","44.45","","1141.67","481.21","1141.67","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.74","44.45","","76.54","76.54","76.54","1 through 10","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","WELLPOINT [1015]","HB CH WELLPOINT","1028.41","77.91","","273.64","94.28","1367.51","138","586.74","1028.41","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","782.76","59.3","","720.78","230.14","2010.94","427","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","782.76","59.3","","344.45","344.45","344.45","1 through 10","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","1120.13","1120.13","1120.13","1 through 10","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","456.17","105.33","1284.66","242","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","464.71","67.87","1012.10","221","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","293.04","293.04","293.04","11","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","983.89","983.89","983.89","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","461.10","58","","677.18","677.18","677.18","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","496.88","62.5","","46.58","46.58","46.58","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","747.15","747.15","747.15","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","1141.67","481.21","1141.67","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","76.54","76.54","76.54","1 through 10","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","273.64","94.28","1367.51","138","353.38","619.38","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","720.78","230.14","2010.94","427","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","471.44","59.3","","344.45","344.45","344.45","1 through 10","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","1120.13","1120.13","1120.13","1 through 10","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","456.17","105.33","1284.66","242","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","AETNA [1001]","HB CH AETNA HMO / PPO","428.51","58.3","","464.71","67.87","1012.10","221","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","428.51","58.3","","293.04","293.04","293.04","11","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","389.55","53","","983.89","983.89","983.89","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.30","58","","677.18","677.18","677.18","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","459.38","62.5","","46.58","46.58","46.58","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","536.55","73","","747.15","747.15","747.15","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.71","44.45","","1141.67","481.21","1141.67","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.71","44.45","","76.54","76.54","76.54","1 through 10","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","WELLPOINT [1015]","HB CH WELLPOINT","572.64","77.91","","273.64","94.28","1367.51","138","326.71","572.64","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.86","59.3","","720.78","230.14","2010.94","427","367.5","576.61","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","435.86","59.3","","344.45","344.45","344.45","1 through 10","367.5","576.61","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","576.61","78.45","","1120.13","1120.13","1120.13","1 through 10","367.5","576.61","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.61","78.45","","456.17","105.33","1284.66","242","367.5","576.61","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","AETNA [1001]","HB CH AETNA HMO / PPO","662.87","58.3","","464.71","67.87","1012.10","221","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","662.87","58.3","","293.04","293.04","293.04","11","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","602.61","53","","983.89","983.89","983.89","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","659.46","58","","677.18","677.18","677.18","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","710.63","62.5","","46.58","46.58","46.58","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","830.01","73","","747.15","747.15","747.15","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","505.40","44.45","","1141.67","481.21","1141.67","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","505.40","44.45","","76.54","76.54","76.54","1 through 10","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","WELLPOINT [1015]","HB CH WELLPOINT","885.84","77.91","","273.64","94.28","1367.51","138","505.4","885.84","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","674.24","59.3","","720.78","230.14","2010.94","427","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","674.24","59.3","","344.45","344.45","344.45","1 through 10","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","891.98","78.45","","1120.13","1120.13","1120.13","1 through 10","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","891.98","78.45","","456.17","105.33","1284.66","242","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","AETNA [1001]","HB CH AETNA HMO / PPO","926.97","58.3","","464.71","67.87","1012.10","221","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","926.97","58.3","","293.04","293.04","293.04","11","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","842.70","53","","983.89","983.89","983.89","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","922.20","58","","677.18","677.18","677.18","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","993.75","62.5","","46.58","46.58","46.58","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1160.70","73","","747.15","747.15","747.15","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","706.76","44.45","","1141.67","481.21","1141.67","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","706.76","44.45","","76.54","76.54","76.54","1 through 10","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.00","1192.50","WELLPOINT [1015]","HB CH WELLPOINT","1238.77","77.91","","273.64","94.28","1367.51","138","706.76","1238.77","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.00","1192.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","942.87","59.3","","720.78","230.14","2010.94","427","795","1247.36","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.00","1192.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","942.87","59.3","","344.45","344.45","344.45","1 through 10","795","1247.36","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.00","1192.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1247.36","78.45","","1120.13","1120.13","1120.13","1 through 10","795","1247.36","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.00","1192.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1247.36","78.45","","456.17","105.33","1284.66","242","795","1247.36","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","AETNA [1001]","HB CH AETNA HMO / PPO","900.74","58.3","","464.71","67.87","1012.10","221","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","900.74","58.3","","293.04","293.04","293.04","11","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","818.85","53","","983.89","983.89","983.89","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","896.10","58","","677.18","677.18","677.18","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","965.63","62.5","","46.58","46.58","46.58","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1127.85","73","","747.15","747.15","747.15","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.75","44.45","","1141.67","481.21","1141.67","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.75","44.45","","76.54","76.54","76.54","1 through 10","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","WELLPOINT [1015]","HB CH WELLPOINT","1203.71","77.91","","273.64","94.28","1367.51","138","686.75","1203.71","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","916.19","59.3","","720.78","230.14","2010.94","427","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","916.19","59.3","","344.45","344.45","344.45","1 through 10","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1212.05","78.45","","1120.13","1120.13","1120.13","1 through 10","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1212.05","78.45","","456.17","105.33","1284.66","242","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","AETNA [1001]","HB CH AETNA HMO / PPO","594.49","58.3","","464.71","67.87","1012.10","221","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","594.49","58.3","","293.04","293.04","293.04","11","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","540.44","53","","983.89","983.89","983.89","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","591.43","58","","677.18","677.18","677.18","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","637.31","62.5","","46.58","46.58","46.58","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","744.38","73","","747.15","747.15","747.15","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.26","44.45","","1141.67","481.21","1141.67","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.26","44.45","","76.54","76.54","76.54","1 through 10","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1019.70","764.77","WELLPOINT [1015]","HB CH WELLPOINT","794.45","77.91","","273.64","94.28","1367.51","138","453.26","794.45","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1019.70","764.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","604.68","59.3","","720.78","230.14","2010.94","427","509.85","799.95","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1019.70","764.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","604.68","59.3","","344.45","344.45","344.45","1 through 10","509.85","799.95","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1019.70","764.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","799.95","78.45","","1120.13","1120.13","1120.13","1 through 10","509.85","799.95","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM NUMBER 2 JUGGERKNOT SOFT DOUBLE MAXBRAID PRELOADED","SUP-ITM-10094372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1019.70","764.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","799.95","78.45","","456.17","105.33","1284.66","242","509.85","799.95","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","AETNA [1001]","HB CH AETNA HMO / PPO","729.33","58.3","","464.71","67.87","1012.10","221","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","729.33","58.3","","293.04","293.04","293.04","11","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","663.03","53","","983.89","983.89","983.89","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","725.58","58","","677.18","677.18","677.18","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","781.88","62.5","","46.58","46.58","46.58","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","913.23","73","","747.15","747.15","747.15","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","556.07","44.45","","1141.67","481.21","1141.67","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","556.07","44.45","","76.54","76.54","76.54","1 through 10","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","WELLPOINT [1015]","HB CH WELLPOINT","974.65","77.91","","273.64","94.28","1367.51","138","556.07","974.65","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","741.84","59.3","","720.78","230.14","2010.94","427","625.5","981.41","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","741.84","59.3","","344.45","344.45","344.45","1 through 10","625.5","981.41","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","981.41","78.45","","1120.13","1120.13","1120.13","1 through 10","625.5","981.41","percent of total billed charges",""
"ANCHOR SUTURE 22X4.75MM ARTHROSCOPY SWIVELOCK C BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10318123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","981.41","78.45","","456.17","105.33","1284.66","242","625.5","981.41","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","464.71","67.87","1012.10","221","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","293.04","293.04","293.04","11","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","983.89","983.89","983.89","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","677.18","677.18","677.18","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","46.58","46.58","46.58","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","747.15","747.15","747.15","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1141.67","481.21","1141.67","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","76.54","76.54","76.54","1 through 10","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","273.64","94.28","1367.51","138","560.07","981.67","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","720.78","230.14","2010.94","427","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","344.45","344.45","344.45","1 through 10","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1120.13","1120.13","1120.13","1 through 10","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","456.17","105.33","1284.66","242","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","AETNA [1001]","HB CH AETNA HMO / PPO","545.69","58.3","","464.71","67.87","1012.10","221","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","545.69","58.3","","293.04","293.04","293.04","11","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","496.08","53","","983.89","983.89","983.89","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","542.88","58","","677.18","677.18","677.18","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","585.00","62.5","","46.58","46.58","46.58","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","683.28","73","","747.15","747.15","747.15","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.05","44.45","","1141.67","481.21","1141.67","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.05","44.45","","76.54","76.54","76.54","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","WELLPOINT [1015]","HB CH WELLPOINT","729.24","77.91","","273.64","94.28","1367.51","138","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","555.05","59.3","","720.78","230.14","2010.94","427","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","555.05","59.3","","344.45","344.45","344.45","1 through 10","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","734.29","78.45","","1120.13","1120.13","1120.13","1 through 10","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","734.29","78.45","","456.17","105.33","1284.66","242","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE 3MM PEEK RAPTORMITE","SUP-ITM-10049660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","AETNA [1001]","HB CH AETNA HMO / PPO","673.37","58.3","","464.71","67.87","1012.10","221","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","673.37","58.3","","293.04","293.04","293.04","11","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","612.15","53","","983.89","983.89","983.89","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","669.90","58","","677.18","677.18","677.18","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","721.88","62.5","","46.58","46.58","46.58","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","747.15","747.15","747.15","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","1141.67","481.21","1141.67","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","76.54","76.54","76.54","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","WELLPOINT [1015]","HB CH WELLPOINT","899.86","77.91","","273.64","94.28","1367.51","138","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","684.92","59.3","","720.78","230.14","2010.94","427","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","684.92","59.3","","344.45","344.45","344.45","1 through 10","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","1120.13","1120.13","1120.13","1 through 10","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","456.17","105.33","1284.66","242","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","AETNA [1001]","HB CH AETNA HMO / PPO","673.37","58.3","","464.71","67.87","1012.10","221","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","673.37","58.3","","293.04","293.04","293.04","11","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","612.15","53","","983.89","983.89","983.89","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","669.90","58","","677.18","677.18","677.18","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","721.88","62.5","","46.58","46.58","46.58","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","747.15","747.15","747.15","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","1141.67","481.21","1141.67","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","76.54","76.54","76.54","1 through 10","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","WELLPOINT [1015]","HB CH WELLPOINT","899.86","77.91","","273.64","94.28","1367.51","138","513.4","899.86","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","684.92","59.3","","720.78","230.14","2010.94","427","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","684.92","59.3","","344.45","344.45","344.45","1 through 10","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","1120.13","1120.13","1120.13","1 through 10","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5 BR HEALIX ADVANCE DYNACORD 3","SUP-ITM-10230121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","456.17","105.33","1284.66","242","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","464.71","67.87","1012.10","221","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","293.04","293.04","293.04","11","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","983.89","983.89","983.89","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","487.20","58","","677.18","677.18","677.18","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","525.00","62.5","","46.58","46.58","46.58","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","747.15","747.15","747.15","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","1141.67","481.21","1141.67","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","76.54","76.54","76.54","1 through 10","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","273.64","94.28","1367.51","138","373.38","654.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","720.78","230.14","2010.94","427","420","658.98","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","498.12","59.3","","344.45","344.45","344.45","1 through 10","420","658.98","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","1120.13","1120.13","1120.13","1 through 10","420","658.98","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM HEALIX PEEK ORTHOCORD NONABSORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10030997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","456.17","105.33","1284.66","242","420","658.98","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","AETNA [1001]","HB CH AETNA HMO / PPO","924.80","58.3","","464.71","67.87","1012.10","221","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","924.80","58.3","","293.04","293.04","293.04","11","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","840.73","53","","983.89","983.89","983.89","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","920.04","58","","677.18","677.18","677.18","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","991.43","62.5","","46.58","46.58","46.58","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1157.98","73","","747.15","747.15","747.15","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","705.10","44.45","","1141.67","481.21","1141.67","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","705.10","44.45","","76.54","76.54","76.54","1 through 10","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.28","1189.71","WELLPOINT [1015]","HB CH WELLPOINT","1235.87","77.91","","273.64","94.28","1367.51","138","705.1","1235.87","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.28","1189.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","940.66","59.3","","720.78","230.14","2010.94","427","793.14","1244.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.28","1189.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","940.66","59.3","","344.45","344.45","344.45","1 through 10","793.14","1244.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.28","1189.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1244.44","78.45","","1120.13","1120.13","1120.13","1 through 10","793.14","1244.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.28","1189.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1244.44","78.45","","456.17","105.33","1284.66","242","793.14","1244.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","AETNA [1001]","HB CH AETNA HMO / PPO","472.23","58.3","","464.71","67.87","1012.10","221","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","472.23","58.3","","293.04","293.04","293.04","11","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","429.30","53","","983.89","983.89","983.89","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","469.80","58","","677.18","677.18","677.18","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","506.25","62.5","","46.58","46.58","46.58","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","591.30","73","","747.15","747.15","747.15","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.05","44.45","","1141.67","481.21","1141.67","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.05","44.45","","76.54","76.54","76.54","1 through 10","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","WELLPOINT [1015]","HB CH WELLPOINT","631.07","77.91","","273.64","94.28","1367.51","138","360.05","631.07","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","480.33","59.3","","720.78","230.14","2010.94","427","405","635.45","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","480.33","59.3","","344.45","344.45","344.45","1 through 10","405","635.45","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","635.45","78.45","","1120.13","1120.13","1120.13","1 through 10","405","635.45","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM RADIOLUCENT HEALIX ADVANCE BIOCRYL RAPIDE","SUP-ITM-10114324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","635.45","78.45","","456.17","105.33","1284.66","242","405","635.45","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","464.71","67.87","1012.10","221","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","293.04","293.04","293.04","11","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","983.89","983.89","983.89","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","677.18","677.18","677.18","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","46.58","46.58","46.58","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","747.15","747.15","747.15","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1141.67","481.21","1141.67","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","76.54","76.54","76.54","1 through 10","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","273.64","94.28","1367.51","138","1066.8","1869.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","720.78","230.14","2010.94","427","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","344.45","344.45","344.45","1 through 10","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1120.13","1120.13","1120.13","1 through 10","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","456.17","105.33","1284.66","242","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","464.71","67.87","1012.10","221","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","293.04","293.04","293.04","11","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","983.89","983.89","983.89","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","513.30","58","","677.18","677.18","677.18","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","553.13","62.5","","46.58","46.58","46.58","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","747.15","747.15","747.15","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","1141.67","481.21","1141.67","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","76.54","76.54","76.54","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","273.64","94.28","1367.51","138","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","720.78","230.14","2010.94","427","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","524.81","59.3","","344.45","344.45","344.45","1 through 10","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","1120.13","1120.13","1120.13","1 through 10","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","456.17","105.33","1284.66","242","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","1530.90","1160.93","1884.08","89","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","5253.92","5253.92","5253.92","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.10","58","","12181.47","12181.47","12181.47","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","590.63","62.5","","1350.68","1350.68","1350.68","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","1910.74","891.94","1910.74","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","1829.79","1561.50","2617.12","88","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","1359.46","1201.30","1689.00","61","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.39","59.3","","1718.92","1718.92","1718.92","1 through 10","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL RSB ULTRATAPE BLUE ULTRABRAID","SUP-ITM-10191573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","1910.74","1019.06","2344.84","74","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","464.71","67.87","1012.10","221","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","293.04","293.04","293.04","11","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","983.89","983.89","983.89","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.10","58","","677.18","677.18","677.18","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","590.63","62.5","","46.58","46.58","46.58","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","747.15","747.15","747.15","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","1141.67","481.21","1141.67","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","76.54","76.54","76.54","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","273.64","94.28","1367.51","138","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","720.78","230.14","2010.94","427","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.39","59.3","","344.45","344.45","344.45","1 through 10","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","1120.13","1120.13","1120.13","1 through 10","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","456.17","105.33","1284.66","242","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","AETNA [1001]","HB CH AETNA HMO / PPO","2536.05","58.3","","464.71","67.87","1012.10","221","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2536.05","58.3","","293.04","293.04","293.04","11","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2305.50","53","","983.89","983.89","983.89","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2523.00","58","","677.18","677.18","677.18","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2718.75","62.5","","46.58","46.58","46.58","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3175.50","73","","747.15","747.15","747.15","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","1141.67","481.21","1141.67","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","76.54","76.54","76.54","1 through 10","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB CH WELLPOINT","3389.09","77.91","","273.64","94.28","1367.51","138","1933.58","3389.09","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2579.55","59.3","","720.78","230.14","2010.94","427","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2579.55","59.3","","344.45","344.45","344.45","1 through 10","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","1120.13","1120.13","1120.13","1 through 10","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","456.17","105.33","1284.66","242","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","AETNA [1001]","HB CH AETNA HMO / PPO","545.69","58.3","","464.71","67.87","1012.10","221","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","545.69","58.3","","293.04","293.04","293.04","11","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","496.08","53","","983.89","983.89","983.89","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","542.88","58","","677.18","677.18","677.18","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","585.00","62.5","","46.58","46.58","46.58","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","683.28","73","","747.15","747.15","747.15","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.05","44.45","","1141.67","481.21","1141.67","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.05","44.45","","76.54","76.54","76.54","1 through 10","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","WELLPOINT [1015]","HB CH WELLPOINT","729.24","77.91","","273.64","94.28","1367.51","138","416.05","729.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","555.05","59.3","","720.78","230.14","2010.94","427","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","555.05","59.3","","344.45","344.45","344.45","1 through 10","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","734.29","78.45","","1120.13","1120.13","1120.13","1 through 10","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY HEALIX ADVANCE BIOCRYL RAPIDE ORTHOCORD","SUP-ITM-10147247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","734.29","78.45","","456.17","105.33","1284.66","242","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","AETNA [1001]","HB CH AETNA HMO / PPO","805.75","58.3","","464.71","67.87","1012.10","221","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","805.75","58.3","","293.04","293.04","293.04","11","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","732.50","53","","983.89","983.89","983.89","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","801.60","58","","677.18","677.18","677.18","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","863.79","62.5","","46.58","46.58","46.58","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1008.91","73","","747.15","747.15","747.15","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","44.45","","1141.67","481.21","1141.67","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","44.45","","76.54","76.54","76.54","1 through 10","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.07","1036.55","WELLPOINT [1015]","HB CH WELLPOINT","1076.77","77.91","","273.64","94.28","1367.51","138","614.33","1076.77","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.07","1036.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","819.57","59.3","","720.78","230.14","2010.94","427","691.04","1084.23","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.07","1036.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","819.57","59.3","","344.45","344.45","344.45","1 through 10","691.04","1084.23","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.07","1036.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1084.23","78.45","","1120.13","1120.13","1120.13","1 through 10","691.04","1084.23","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM BIOSTEON INTRALINE NEEDLE TRIPLE LOADED BX/5EA","SUP-ITM-10216968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.07","1036.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1084.23","78.45","","456.17","105.33","1284.66","242","691.04","1084.23","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL KNOTLESS REGENESORB SELF TAPPING","SUP-ITM-10275331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","464.71","67.87","1012.10","221","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","293.04","293.04","293.04","11","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","983.89","983.89","983.89","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.10","58","","677.18","677.18","677.18","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","590.63","62.5","","46.58","46.58","46.58","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","747.15","747.15","747.15","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","1141.67","481.21","1141.67","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","76.54","76.54","76.54","1 through 10","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","273.64","94.28","1367.51","138","420.05","736.25","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","720.78","230.14","2010.94","427","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.39","59.3","","344.45","344.45","344.45","1 through 10","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","1120.13","1120.13","1120.13","1 through 10","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","456.17","105.33","1284.66","242","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","AETNA [1001]","HB CH AETNA HMO / PPO","508.96","58.3","","464.71","67.87","1012.10","221","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","508.96","58.3","","293.04","293.04","293.04","11","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","462.69","53","","983.89","983.89","983.89","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","506.34","58","","677.18","677.18","677.18","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","545.63","62.5","","46.58","46.58","46.58","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","637.29","73","","747.15","747.15","747.15","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","388.05","44.45","","1141.67","481.21","1141.67","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","388.05","44.45","","76.54","76.54","76.54","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","WELLPOINT [1015]","HB CH WELLPOINT","680.15","77.91","","273.64","94.28","1367.51","138","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","517.69","59.3","","720.78","230.14","2010.94","427","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","517.69","59.3","","344.45","344.45","344.45","1 through 10","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","684.87","78.45","","1120.13","1120.13","1120.13","1 through 10","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX ADVANCE PEK 3 ORTHOCORD","SUP-ITM-10148730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","684.87","78.45","","456.17","105.33","1284.66","242","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","AETNA [1001]","HB CH AETNA HMO / PPO","508.96","58.3","","464.71","67.87","1012.10","221","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","508.96","58.3","","293.04","293.04","293.04","11","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","462.69","53","","983.89","983.89","983.89","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","506.34","58","","677.18","677.18","677.18","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","545.63","62.5","","46.58","46.58","46.58","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","637.29","73","","747.15","747.15","747.15","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","388.05","44.45","","1141.67","481.21","1141.67","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","388.05","44.45","","76.54","76.54","76.54","1 through 10","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","both","","","873.00","654.75","WELLPOINT [1015]","HB CH WELLPOINT","680.15","77.91","","273.64","94.28","1367.51","138","388.05","680.15","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","517.69","59.3","","720.78","230.14","2010.94","427","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","517.69","59.3","","344.45","344.45","344.45","1 through 10","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","684.87","78.45","","1120.13","1120.13","1120.13","1 through 10","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALIX PEEK ORTHOCORD NONABSORBALE 3 STRAND","SUP-ITM-10030998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","684.87","78.45","","456.17","105.33","1284.66","242","436.5","684.87","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","AETNA [1001]","HB CH AETNA HMO / PPO","559.68","58.3","","464.71","67.87","1012.10","221","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","559.68","58.3","","293.04","293.04","293.04","11","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.80","53","","983.89","983.89","983.89","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","556.80","58","","677.18","677.18","677.18","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","600.00","62.5","","46.58","46.58","46.58","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","700.80","73","","747.15","747.15","747.15","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.72","44.45","","1141.67","481.21","1141.67","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.72","44.45","","76.54","76.54","76.54","1 through 10","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","WELLPOINT [1015]","HB CH WELLPOINT","747.94","77.91","","273.64","94.28","1367.51","138","426.72","747.94","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","569.28","59.3","","720.78","230.14","2010.94","427","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","569.28","59.3","","344.45","344.45","344.45","1 through 10","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","753.12","78.45","","1120.13","1120.13","1120.13","1 through 10","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.12","78.45","","456.17","105.33","1284.66","242","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","464.71","67.87","1012.10","221","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.88","58.3","","293.04","293.04","293.04","11","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","983.89","983.89","983.89","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.50","58","","677.18","677.18","677.18","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.13","62.5","","46.58","46.58","46.58","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","747.15","747.15","747.15","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","1141.67","481.21","1141.67","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","76.54","76.54","76.54","1 through 10","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","273.64","94.28","1367.51","138","500.06","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","720.78","230.14","2010.94","427","562.5","882.56","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.13","59.3","","344.45","344.45","344.45","1 through 10","562.5","882.56","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","1120.13","1120.13","1120.13","1 through 10","562.5","882.56","percent of total billed charges",""
"ANCHOR SUTURE 5.MM HEALICOIL KNOTLESS PK","SUP-ITM-10275330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","456.17","105.33","1284.66","242","562.5","882.56","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","AETNA [1001]","HB CH AETNA HMO / PPO","589.41","58.3","","464.71","67.87","1012.10","221","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","589.41","58.3","","293.04","293.04","293.04","11","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","535.83","53","","983.89","983.89","983.89","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","586.38","58","","677.18","677.18","677.18","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","631.88","62.5","","46.58","46.58","46.58","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","738.03","73","","747.15","747.15","747.15","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","449.39","44.45","","1141.67","481.21","1141.67","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","449.39","44.45","","76.54","76.54","76.54","1 through 10","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.00","758.25","WELLPOINT [1015]","HB CH WELLPOINT","787.67","77.91","","273.64","94.28","1367.51","138","449.39","787.67","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.00","758.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","599.52","59.3","","720.78","230.14","2010.94","427","505.5","793.13","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.00","758.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","599.52","59.3","","344.45","344.45","344.45","1 through 10","505.5","793.13","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.00","758.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","793.13","78.45","","1120.13","1120.13","1120.13","1 through 10","505.5","793.13","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM TWINFIX TWO NUMBER 2 ULTRABRAID NEEDLE TITANIUM","SUP-ITM-10041540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.00","758.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","793.13","78.45","","456.17","105.33","1284.66","242","505.5","793.13","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","AETNA [1001]","HB CH AETNA HMO / PPO","444.32","58.3","","464.71","67.87","1012.10","221","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","444.32","58.3","","293.04","293.04","293.04","11","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","403.92","53","","983.89","983.89","983.89","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","442.03","58","","677.18","677.18","677.18","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","476.33","62.5","","46.58","46.58","46.58","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","556.35","73","","747.15","747.15","747.15","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.76","44.45","","1141.67","481.21","1141.67","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.76","44.45","","76.54","76.54","76.54","1 through 10","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.12","571.59","WELLPOINT [1015]","HB CH WELLPOINT","593.77","77.91","","273.64","94.28","1367.51","138","338.76","593.77","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.12","571.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","451.94","59.3","","720.78","230.14","2010.94","427","381.06","597.88","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.12","571.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","451.94","59.3","","344.45","344.45","344.45","1 through 10","381.06","597.88","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.12","571.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","597.88","78.45","","1120.13","1120.13","1120.13","1 through 10","381.06","597.88","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.12","571.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","597.88","78.45","","456.17","105.33","1284.66","242","381.06","597.88","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","464.71","67.87","1012.10","221","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","708.35","58.3","","293.04","293.04","293.04","11","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","643.95","53","","983.89","983.89","983.89","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","704.70","58","","677.18","677.18","677.18","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","759.38","62.5","","46.58","46.58","46.58","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","747.15","747.15","747.15","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","1141.67","481.21","1141.67","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","76.54","76.54","76.54","1 through 10","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","273.64","94.28","1367.51","138","540.07","946.61","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","720.78","230.14","2010.94","427","607.5","953.17","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","720.50","59.3","","344.45","344.45","344.45","1 through 10","607.5","953.17","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","1120.13","1120.13","1120.13","1 through 10","607.5","953.17","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","456.17","105.33","1284.66","242","607.5","953.17","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","AETNA [1001]","HB CH AETNA HMO / PPO","1040.66","58.3","","464.71","67.87","1012.10","221","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1040.66","58.3","","293.04","293.04","293.04","11","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","946.05","53","","983.89","983.89","983.89","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1035.30","58","","677.18","677.18","677.18","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1115.63","62.5","","46.58","46.58","46.58","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1303.05","73","","747.15","747.15","747.15","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.43","44.45","","1141.67","481.21","1141.67","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.43","44.45","","76.54","76.54","76.54","1 through 10","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","WELLPOINT [1015]","HB CH WELLPOINT","1390.69","77.91","","273.64","94.28","1367.51","138","793.43","1390.69","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1058.51","59.3","","720.78","230.14","2010.94","427","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1058.51","59.3","","344.45","344.45","344.45","1 through 10","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1400.33","78.45","","1120.13","1120.13","1120.13","1 through 10","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1400.33","78.45","","456.17","105.33","1284.66","242","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","AETNA [1001]","HB CH AETNA HMO / PPO","813.29","58.3","","464.71","67.87","1012.10","221","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","813.29","58.3","","293.04","293.04","293.04","11","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","739.35","53","","983.89","983.89","983.89","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","809.10","58","","677.18","677.18","677.18","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","871.88","62.5","","46.58","46.58","46.58","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1018.35","73","","747.15","747.15","747.15","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.08","44.45","","1141.67","481.21","1141.67","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.08","44.45","","76.54","76.54","76.54","1 through 10","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","WELLPOINT [1015]","HB CH WELLPOINT","1086.84","77.91","","273.64","94.28","1367.51","138","620.08","1086.84","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","827.24","59.3","","720.78","230.14","2010.94","427","697.5","1094.38","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","827.24","59.3","","344.45","344.45","344.45","1 through 10","697.5","1094.38","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1094.38","78.45","","1120.13","1120.13","1120.13","1 through 10","697.5","1094.38","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1094.38","78.45","","456.17","105.33","1284.66","242","697.5","1094.38","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","464.71","67.87","1012.10","221","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","293.04","293.04","293.04","11","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","983.89","983.89","983.89","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","391.50","58","","677.18","677.18","677.18","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.88","62.5","","46.58","46.58","46.58","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","747.15","747.15","747.15","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","1141.67","481.21","1141.67","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","76.54","76.54","76.54","1 through 10","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","273.64","94.28","1367.51","138","300.04","525.89","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","720.78","230.14","2010.94","427","337.5","529.54","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.28","59.3","","344.45","344.45","344.45","1 through 10","337.5","529.54","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","1120.13","1120.13","1120.13","1 through 10","337.5","529.54","percent of total billed charges",""
"ANCHOR SUTURE FIX 46IN CV 1.7MM S ONE ULTRABRAID","SUP-ITM-10216723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","456.17","105.33","1284.66","242","337.5","529.54","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","AETNA [1001]","HB CH AETNA HMO / PPO","568.43","58.3","","464.71","67.87","1012.10","221","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","568.43","58.3","","293.04","293.04","293.04","11","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.75","53","","983.89","983.89","983.89","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","565.50","58","","677.18","677.18","677.18","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","609.38","62.5","","46.58","46.58","46.58","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","711.75","73","","747.15","747.15","747.15","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.39","44.45","","1141.67","481.21","1141.67","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.39","44.45","","76.54","76.54","76.54","1 through 10","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","WELLPOINT [1015]","HB CH WELLPOINT","759.62","77.91","","273.64","94.28","1367.51","138","433.39","759.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","578.18","59.3","","720.78","230.14","2010.94","427","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","578.18","59.3","","344.45","344.45","344.45","1 through 10","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","764.89","78.45","","1120.13","1120.13","1120.13","1 through 10","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.89","78.45","","456.17","105.33","1284.66","242","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","AETNA [1001]","HB CH AETNA HMO / PPO","599.91","58.3","","464.71","67.87","1012.10","221","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","599.91","58.3","","293.04","293.04","293.04","11","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","545.37","53","","983.89","983.89","983.89","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","596.82","58","","677.18","677.18","677.18","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","643.13","62.5","","46.58","46.58","46.58","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","747.15","747.15","747.15","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","1141.67","481.21","1141.67","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","76.54","76.54","76.54","1 through 10","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB CH WELLPOINT","801.69","77.91","","273.64","94.28","1367.51","138","457.39","801.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","610.20","59.3","","720.78","230.14","2010.94","427","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","610.20","59.3","","344.45","344.45","344.45","1 through 10","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","1120.13","1120.13","1120.13","1 through 10","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","456.17","105.33","1284.66","242","514.5","807.25","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","AETNA [1001]","HB CH AETNA HMO / PPO","556.18","58.3","","464.71","67.87","1012.10","221","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","556.18","58.3","","293.04","293.04","293.04","11","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.62","53","","983.89","983.89","983.89","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","553.32","58","","677.18","677.18","677.18","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","596.25","62.5","","46.58","46.58","46.58","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","747.15","747.15","747.15","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.05","44.45","","1141.67","481.21","1141.67","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.05","44.45","","76.54","76.54","76.54","1 through 10","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","WELLPOINT [1015]","HB CH WELLPOINT","743.26","77.91","","273.64","94.28","1367.51","138","424.05","743.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","565.72","59.3","","720.78","230.14","2010.94","427","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","565.72","59.3","","344.45","344.45","344.45","1 through 10","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","748.41","78.45","","1120.13","1120.13","1120.13","1 through 10","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.41","78.45","","456.17","105.33","1284.66","242","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","AETNA [1001]","HB CH AETNA HMO / PPO","622.64","58.3","","464.71","67.87","1012.10","221","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","622.64","58.3","","293.04","293.04","293.04","11","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","566.04","53","","983.89","983.89","983.89","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","619.44","58","","677.18","677.18","677.18","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","667.50","62.5","","46.58","46.58","46.58","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","779.64","73","","747.15","747.15","747.15","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","474.73","44.45","","1141.67","481.21","1141.67","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","474.73","44.45","","76.54","76.54","76.54","1 through 10","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.00","801.00","WELLPOINT [1015]","HB CH WELLPOINT","832.08","77.91","","273.64","94.28","1367.51","138","474.73","832.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.00","801.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","633.32","59.3","","720.78","230.14","2010.94","427","534","837.85","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.00","801.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","633.32","59.3","","344.45","344.45","344.45","1 through 10","534","837.85","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.00","801.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","837.85","78.45","","1120.13","1120.13","1120.13","1 through 10","534","837.85","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY PITON SHOULDER FORCE FIBER KNOTLESS","SUP-ITM-10048242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.00","801.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","837.85","78.45","","456.17","105.33","1284.66","242","534","837.85","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 MINILOK QUICK PLUS ORTHOCORD BIO ABSORBABLE BIT NEEDLE V5","SUP-ITM-10030989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","AETNA [1001]","HB CH AETNA HMO / PPO","327.06","58.3","","464.71","67.87","1012.10","221","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","327.06","58.3","","293.04","293.04","293.04","11","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","297.33","53","","983.89","983.89","983.89","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","325.38","58","","677.18","677.18","677.18","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","350.63","62.5","","46.58","46.58","46.58","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","409.53","73","","747.15","747.15","747.15","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","1141.67","481.21","1141.67","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","76.54","76.54","76.54","1 through 10","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","WELLPOINT [1015]","HB CH WELLPOINT","437.08","77.91","","273.64","94.28","1367.51","138","249.36","437.08","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","332.67","59.3","","720.78","230.14","2010.94","427","280.5","440.1","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","332.67","59.3","","344.45","344.45","344.45","1 through 10","280.5","440.1","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","1120.13","1120.13","1120.13","1 through 10","280.5","440.1","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","456.17","105.33","1284.66","242","280.5","440.1","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","AETNA [1001]","HB CH AETNA HMO / PPO","591.16","58.3","","464.71","67.87","1012.10","221","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","591.16","58.3","","293.04","293.04","293.04","11","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.42","53","","983.89","983.89","983.89","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","588.12","58","","677.18","677.18","677.18","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","633.75","62.5","","46.58","46.58","46.58","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","740.22","73","","747.15","747.15","747.15","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.72","44.45","","1141.67","481.21","1141.67","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.72","44.45","","76.54","76.54","76.54","1 through 10","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","WELLPOINT [1015]","HB CH WELLPOINT","790.01","77.91","","273.64","94.28","1367.51","138","450.72","790.01","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","601.30","59.3","","720.78","230.14","2010.94","427","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","601.30","59.3","","344.45","344.45","344.45","1 through 10","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","795.48","78.45","","1120.13","1120.13","1120.13","1 through 10","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.48","78.45","","456.17","105.33","1284.66","242","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","AETNA [1001]","HB CH AETNA HMO / PPO","540.37","58.3","","464.71","67.87","1012.10","221","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","540.37","58.3","","293.04","293.04","293.04","11","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","491.25","53","","983.89","983.89","983.89","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","537.59","58","","677.18","677.18","677.18","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","579.30","62.5","","46.58","46.58","46.58","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","676.62","73","","747.15","747.15","747.15","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.00","44.45","","1141.67","481.21","1141.67","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.00","44.45","","76.54","76.54","76.54","1 through 10","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.88","695.16","WELLPOINT [1015]","HB CH WELLPOINT","722.13","77.91","","273.64","94.28","1367.51","138","412","722.13","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.88","695.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","549.64","59.3","","720.78","230.14","2010.94","427","463.44","727.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.88","695.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","549.64","59.3","","344.45","344.45","344.45","1 through 10","463.44","727.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.88","695.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","727.14","78.45","","1120.13","1120.13","1120.13","1 through 10","463.44","727.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 LENGTH2.8MM ARTHROSCOPY Y KNOT RC ALL TRIPLE LOADED HI FI","SUP-ITM-10158285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.88","695.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","727.14","78.45","","456.17","105.33","1284.66","242","463.44","727.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","AETNA [1001]","HB CH AETNA HMO / PPO","629.64","58.3","","464.71","67.87","1012.10","221","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","629.64","58.3","","293.04","293.04","293.04","11","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","572.40","53","","983.89","983.89","983.89","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","626.40","58","","677.18","677.18","677.18","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","675.00","62.5","","46.58","46.58","46.58","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","788.40","73","","747.15","747.15","747.15","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.06","44.45","","1141.67","481.21","1141.67","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.06","44.45","","76.54","76.54","76.54","1 through 10","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","WELLPOINT [1015]","HB CH WELLPOINT","841.43","77.91","","273.64","94.28","1367.51","138","480.06","841.43","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","640.44","59.3","","720.78","230.14","2010.94","427","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","640.44","59.3","","344.45","344.45","344.45","1 through 10","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","847.26","78.45","","1120.13","1120.13","1120.13","1 through 10","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","847.26","78.45","","456.17","105.33","1284.66","242","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","464.71","67.87","1012.10","221","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","293.04","293.04","293.04","11","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","983.89","983.89","983.89","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","513.30","58","","677.18","677.18","677.18","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","553.13","62.5","","46.58","46.58","46.58","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","747.15","747.15","747.15","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","1141.67","481.21","1141.67","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","76.54","76.54","76.54","1 through 10","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","273.64","94.28","1367.51","138","393.38","689.5","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","720.78","230.14","2010.94","427","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","524.81","59.3","","344.45","344.45","344.45","1 through 10","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","1120.13","1120.13","1120.13","1 through 10","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","456.17","105.33","1284.66","242","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 1.9MM ENDOSCOPY SUTUREFIX ULTRA COBRAID BLUE","SUP-ITM-10126700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","464.71","67.87","1012.10","221","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","293.04","293.04","293.04","11","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","983.89","983.89","983.89","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","504.60","58","","677.18","677.18","677.18","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","543.75","62.5","","46.58","46.58","46.58","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","747.15","747.15","747.15","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","1141.67","481.21","1141.67","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","76.54","76.54","76.54","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","273.64","94.28","1367.51","138","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","720.78","230.14","2010.94","427","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","515.91","59.3","","344.45","344.45","344.45","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","1120.13","1120.13","1120.13","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","456.17","105.33","1284.66","242","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","AETNA [1001]","HB CH AETNA HMO / PPO","731.82","58.3","","464.71","67.87","1012.10","221","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","731.82","58.3","","293.04","293.04","293.04","11","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","665.29","53","","983.89","983.89","983.89","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","728.05","58","","677.18","677.18","677.18","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","784.54","62.5","","46.58","46.58","46.58","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","916.34","73","","747.15","747.15","747.15","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.96","44.45","","1141.67","481.21","1141.67","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.96","44.45","","76.54","76.54","76.54","1 through 10","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1255.26","941.44","WELLPOINT [1015]","HB CH WELLPOINT","977.97","77.91","","273.64","94.28","1367.51","138","557.96","977.97","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1255.26","941.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","744.37","59.3","","720.78","230.14","2010.94","427","627.63","984.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1255.26","941.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","744.37","59.3","","344.45","344.45","344.45","1 through 10","627.63","984.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1255.26","941.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","984.75","78.45","","1120.13","1120.13","1120.13","1 through 10","627.63","984.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ICONIX INTELLIBRAID FORCE FIBER 2 STRAND PK/5EA","SUP-ITM-10306209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1255.26","941.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","984.75","78.45","","456.17","105.33","1284.66","242","627.63","984.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","464.71","67.87","1012.10","221","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","293.04","293.04","293.04","11","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","983.89","983.89","983.89","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","504.60","58","","677.18","677.18","677.18","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","543.75","62.5","","46.58","46.58","46.58","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","747.15","747.15","747.15","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","1141.67","481.21","1141.67","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","76.54","76.54","76.54","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","273.64","94.28","1367.51","138","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","720.78","230.14","2010.94","427","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","515.91","59.3","","344.45","344.45","344.45","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","1120.13","1120.13","1120.13","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","456.17","105.33","1284.66","242","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","464.71","67.87","1012.10","221","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.47","58.3","","293.04","293.04","293.04","11","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","983.89","983.89","983.89","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.90","58","","677.18","677.18","677.18","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","534.38","62.5","","46.58","46.58","46.58","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","747.15","747.15","747.15","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","1141.67","481.21","1141.67","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","76.54","76.54","76.54","1 through 10","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","273.64","94.28","1367.51","138","380.05","666.13","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","720.78","230.14","2010.94","427","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","507.02","59.3","","344.45","344.45","344.45","1 through 10","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","1120.13","1120.13","1120.13","1 through 10","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","456.17","105.33","1284.66","242","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","AETNA [1001]","HB CH AETNA HMO / PPO","542.19","58.3","","464.71","67.87","1012.10","221","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","542.19","58.3","","293.04","293.04","293.04","11","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","492.90","53","","983.89","983.89","983.89","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","539.40","58","","677.18","677.18","677.18","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","581.25","62.5","","46.58","46.58","46.58","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","678.90","73","","747.15","747.15","747.15","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.39","44.45","","1141.67","481.21","1141.67","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.39","44.45","","76.54","76.54","76.54","1 through 10","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","WELLPOINT [1015]","HB CH WELLPOINT","724.56","77.91","","273.64","94.28","1367.51","138","413.39","724.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","551.49","59.3","","720.78","230.14","2010.94","427","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","551.49","59.3","","344.45","344.45","344.45","1 through 10","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","729.59","78.45","","1120.13","1120.13","1120.13","1 through 10","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","729.59","78.45","","456.17","105.33","1284.66","242","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","AETNA [1001]","HB CH AETNA HMO / PPO","703.10","58.3","","464.71","67.87","1012.10","221","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","703.10","58.3","","293.04","293.04","293.04","11","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","639.18","53","","983.89","983.89","983.89","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","699.48","58","","677.18","677.18","677.18","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","753.75","62.5","","46.58","46.58","46.58","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","880.38","73","","747.15","747.15","747.15","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.07","44.45","","1141.67","481.21","1141.67","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.07","44.45","","76.54","76.54","76.54","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","WELLPOINT [1015]","HB CH WELLPOINT","939.59","77.91","","273.64","94.28","1367.51","138","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","715.16","59.3","","720.78","230.14","2010.94","427","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","715.16","59.3","","344.45","344.45","344.45","1 through 10","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","946.11","78.45","","1120.13","1120.13","1120.13","1 through 10","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ARTHROSCOPY ULTRA TI TITANIUM DISPOSABLE 2 WHITE COBRAID BLUE","SUP-ITM-10079980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","946.11","78.45","","456.17","105.33","1284.66","242","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","AETNA [1001]","HB CH AETNA HMO / PPO","605.29","58.3","","464.71","67.87","1012.10","221","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","605.29","58.3","","293.04","293.04","293.04","11","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","550.27","53","","983.89","983.89","983.89","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","602.18","58","","677.18","677.18","677.18","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","648.90","62.5","","46.58","46.58","46.58","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","757.92","73","","747.15","747.15","747.15","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.50","44.45","","1141.67","481.21","1141.67","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.50","44.45","","76.54","76.54","76.54","1 through 10","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.24","778.68","WELLPOINT [1015]","HB CH WELLPOINT","808.89","77.91","","273.64","94.28","1367.51","138","461.5","808.89","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.24","778.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","615.68","59.3","","720.78","230.14","2010.94","427","519.12","814.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.24","778.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","615.68","59.3","","344.45","344.45","344.45","1 through 10","519.12","814.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.24","778.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","814.50","78.45","","1120.13","1120.13","1120.13","1 through 10","519.12","814.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM ALLTHREAD MAXBRAID TITANIUM","SUP-ITM-10266539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.24","778.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","814.50","78.45","","456.17","105.33","1284.66","242","519.12","814.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","AETNA [1001]","HB CH AETNA HMO / PPO","576.61","58.3","","464.71","67.87","1012.10","221","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","576.61","58.3","","293.04","293.04","293.04","11","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","524.19","53","","983.89","983.89","983.89","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","573.64","58","","677.18","677.18","677.18","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","618.15","62.5","","46.58","46.58","46.58","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","722.00","73","","747.15","747.15","747.15","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","439.63","44.45","","1141.67","481.21","1141.67","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","439.63","44.45","","76.54","76.54","76.54","1 through 10","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","both","","","989.04","741.78","WELLPOINT [1015]","HB CH WELLPOINT","770.56","77.91","","273.64","94.28","1367.51","138","439.63","770.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","989.04","741.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","586.50","59.3","","720.78","230.14","2010.94","427","494.52","775.9","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","989.04","741.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","586.50","59.3","","344.45","344.45","344.45","1 through 10","494.52","775.9","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","989.04","741.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","775.90","78.45","","1120.13","1120.13","1120.13","1 through 10","494.52","775.9","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA WHITE COBRAID BLUE BLACK 72202606","SUP-ITM-10079993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","989.04","741.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","775.90","78.45","","456.17","105.33","1284.66","242","494.52","775.9","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","AETNA [1001]","HB CH AETNA HMO / PPO","381.28","58.3","","464.71","67.87","1012.10","221","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","381.28","58.3","","293.04","293.04","293.04","11","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","346.62","53","","983.89","983.89","983.89","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","379.32","58","","677.18","677.18","677.18","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","408.75","62.5","","46.58","46.58","46.58","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","477.42","73","","747.15","747.15","747.15","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","290.70","44.45","","1141.67","481.21","1141.67","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","290.70","44.45","","76.54","76.54","76.54","1 through 10","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","WELLPOINT [1015]","HB CH WELLPOINT","509.53","77.91","","273.64","94.28","1367.51","138","290.7","509.53","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","387.82","59.3","","720.78","230.14","2010.94","427","327","513.06","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","387.82","59.3","","344.45","344.45","344.45","1 through 10","327","513.06","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","513.06","78.45","","1120.13","1120.13","1120.13","1 through 10","327","513.06","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","513.06","78.45","","456.17","105.33","1284.66","242","327","513.06","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","AETNA [1001]","HB CH AETNA HMO / PPO","703.10","58.3","","464.71","67.87","1012.10","221","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","703.10","58.3","","293.04","293.04","293.04","11","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","639.18","53","","983.89","983.89","983.89","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","699.48","58","","677.18","677.18","677.18","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","753.75","62.5","","46.58","46.58","46.58","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","880.38","73","","747.15","747.15","747.15","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.07","44.45","","1141.67","481.21","1141.67","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.07","44.45","","76.54","76.54","76.54","1 through 10","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.00","904.50","WELLPOINT [1015]","HB CH WELLPOINT","939.59","77.91","","273.64","94.28","1367.51","138","536.07","939.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","715.16","59.3","","720.78","230.14","2010.94","427","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","715.16","59.3","","344.45","344.45","344.45","1 through 10","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","946.11","78.45","","1120.13","1120.13","1120.13","1 through 10","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 4.5MM TWINFIX ARTHROSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM COBRAID BLUE","SUP-ITM-10079978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.00","904.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","946.11","78.45","","456.17","105.33","1284.66","242","603","946.11","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","464.71","67.87","1012.10","221","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","293.04","293.04","293.04","11","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","983.89","983.89","983.89","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","504.60","58","","677.18","677.18","677.18","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","543.75","62.5","","46.58","46.58","46.58","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","747.15","747.15","747.15","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","1141.67","481.21","1141.67","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","76.54","76.54","76.54","1 through 10","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","273.64","94.28","1367.51","138","386.72","677.82","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","720.78","230.14","2010.94","427","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","515.91","59.3","","344.45","344.45","344.45","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","1120.13","1120.13","1120.13","1 through 10","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 5.5MM HEALICOIL ULTRABRAID BLACK BLUE COBRAID","SUP-ITM-10118151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","456.17","105.33","1284.66","242","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","464.71","67.87","1012.10","221","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","332.31","58.3","","293.04","293.04","293.04","11","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","983.89","983.89","983.89","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","330.60","58","","677.18","677.18","677.18","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","356.25","62.5","","46.58","46.58","46.58","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","747.15","747.15","747.15","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","1141.67","481.21","1141.67","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","76.54","76.54","76.54","1 through 10","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","273.64","94.28","1367.51","138","253.37","444.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","720.78","230.14","2010.94","427","285","447.17","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","338.01","59.3","","344.45","344.45","344.45","1 through 10","285","447.17","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","1120.13","1120.13","1120.13","1 through 10","285","447.17","percent of total billed charges",""
"ANCHOR SUTURE SZ 2.0 5.5MM TWINFIX ENDOSCOPY ULTRA SOFT TISSUE FIXATION TITANIUM ULTRABRAID WHITE COBRAID BLUE BLACK","SUP-ITM-10079982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","456.17","105.33","1284.66","242","285","447.17","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","AETNA [1001]","HB CH AETNA HMO / PPO","822.03","58.3","","464.71","67.87","1012.10","221","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","822.03","58.3","","293.04","293.04","293.04","11","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","747.30","53","","983.89","983.89","983.89","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","817.80","58","","677.18","677.18","677.18","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","881.25","62.5","","46.58","46.58","46.58","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1029.30","73","","747.15","747.15","747.15","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.75","44.45","","1141.67","481.21","1141.67","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.75","44.45","","76.54","76.54","76.54","1 through 10","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","WELLPOINT [1015]","HB CH WELLPOINT","1098.53","77.91","","273.64","94.28","1367.51","138","626.75","1098.53","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","836.13","59.3","","720.78","230.14","2010.94","427","705","1106.15","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","836.13","59.3","","344.45","344.45","344.45","1 through 10","705","1106.15","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1106.15","78.45","","1120.13","1120.13","1120.13","1 through 10","705","1106.15","percent of total billed charges",""
"ANCHOR SWIVELOCK 4.75MMX24.5MM W/1.3MM SUTURE TAPE WHITE/BLUE SELF PUNCHING BC BX/5EA","SUP-ITM-10320764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1106.15","78.45","","456.17","105.33","1284.66","242","705","1106.15","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","132.11","132.11","132.11","1 through 10","28.69","228","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","136.54","136.54","136.54","1 through 10","30.18","188.28","percent of total billed charges",""
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","24456.48","18342.36","MEDICARE [2001]","HB NWH MEDICARE","6686.44","","Case rate ($6,686.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,247.05, add-ons for qualifying new technology services are included. If operating cost exceeds $51,389.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,406.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,221.72. The transfer operating threshold is the transfer adjustment factor * $6,247.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.72. The transfer capital threshold is the transfer adjustment factor * $464.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6664.61","6664.61","6664.61","1 through 10","5959.59","6905.4887","other","Inpatient DRG"
"Angina Pectoris And Coronary Atherosclerosis,MAJOR","198","DRG","","","","","","","","inpatient","","","33497.33","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","16842.12","","Fee schedule rate ($16,842.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16842.12","16842.12","16842.12","1 through 10","2983","25263.17","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","14816.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12129.44","","Standard inlier is a Case rate ($12,129.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,721.72) for the length of stay and the standard reimbursement.","3286.84","3286.84","3286.84","1 through 10","2983","25263.17","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","20242.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14494.23","","Standard inlier is a Case rate ($14,494.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,491, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,057.40) for the length of stay and the standard reimbursement.","3927.65","3927.65","14494.23","1 through 10","2983","25263.17","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","20242.70","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7998.5406","","Per diem ($5,215). If length of stay < 2, first 1 days paid at a per diem of $10,430 instead.","7998.5406","10429.56","10429.56","1 through 10","2983","25263.17","per diem","Estimated amount calculated based on 1 day length of stay."
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","122.00","91.50","AETNA [1001]","HB CH AETNA HMO / PPO","71.13","58.3","","67.47","67.47","67.47","1 through 10","14.31","115.9","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","122.00","91.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.06","73","","119.00","119.00","119.00","1 through 10","14.31","115.9","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","69.73","69.73","119.00","1 through 10","15.06","95.71","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","91.49","91.49","91.49","1 through 10","15.06","95.71","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1530.90","1160.93","1884.08","89","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","5253.92","5253.92","5253.92","1 through 10","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1084.02","58","","12181.47","12181.47","12181.47","1 through 10","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1168.13","62.5","","1350.68","1350.68","1350.68","1 through 10","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.77","44.45","","1910.74","891.94","1910.74","1 through 10","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","1829.79","1561.50","2617.12","88","830.77","1456.14","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1359.46","1201.30","1689.00","61","934.5","1466.23","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1718.92","1718.92","1718.92","1 through 10","934.5","1466.23","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","1910.74","1019.06","2344.84","74","934.5","1466.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1530.90","1160.93","1884.08","89","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","5253.92","5253.92","5253.92","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2074.95","58","","12181.47","12181.47","12181.47","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2235.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.20","44.45","","1910.74","891.94","1910.74","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","1829.79","1561.50","2617.12","88","1590.2","2787.23","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1359.46","1201.30","1689.00","61","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1718.92","1718.92","1718.92","1 through 10","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","1910.74","1019.06","2344.84","74","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","AETNA [1001]","HB CH AETNA HMO / PPO","2412.16","58.3","","1530.90","1160.93","1884.08","89","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2192.88","53","","5253.92","5253.92","5253.92","1 through 10","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2399.75","58","","12181.47","12181.47","12181.47","1 through 10","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2585.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1839.12","44.45","","1910.74","891.94","1910.74","1 through 10","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","WELLPOINT [1015]","HB CH WELLPOINT","3223.53","77.91","","1829.79","1561.50","2617.12","88","1839.12","3223.53","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2453.54","59.3","","1359.46","1201.30","1689.00","61","2068.75","3245.87","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2453.54","59.3","","1718.92","1718.92","1718.92","1 through 10","2068.75","3245.87","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3245.87","78.45","","1910.74","1019.06","2344.84","74","2068.75","3245.87","percent of total billed charges",""
"ANKLE KIT 3.0CC AUGMENT BONE GRAFT ALLOGRAFT HINDFOOT ARTHRODESIS","SUP-ITM-10158665","CDM","C1734","HCPCS","0278","RC","","","","both","","","6640.00","4980.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3831.28","57.7","","7655.92","2713.50","7655.92","1 through 10","3519.2","6314.64","percent of total billed charges",""
"ANKLE KIT 3.0CC AUGMENT BONE GRAFT ALLOGRAFT HINDFOOT ARTHRODESIS","SUP-ITM-10158665","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","6640.00","4980.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3937.52","59.3","","3891.04","3891.04","3891.04","1 through 10","2951.48","5209.08","percent of total billed charges",""
"ANKLE KIT 3.0CC AUGMENT BONE GRAFT ALLOGRAFT HINDFOOT ARTHRODESIS","SUP-ITM-10158665","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","6640.00","4980.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3831.28","57.7","","7655.92","2713.50","7655.92","1 through 10","2951.48","5209.08","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","464.71","67.87","1012.10","221","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","293.04","293.04","293.04","11","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","983.89","983.89","983.89","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","487.20","58","","677.18","677.18","677.18","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","525.00","62.5","","46.58","46.58","46.58","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","747.15","747.15","747.15","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","1141.67","481.21","1141.67","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","76.54","76.54","76.54","1 through 10","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","273.64","94.28","1367.51","138","373.38","654.44","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","720.78","230.14","2010.94","427","420","658.98","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","498.12","59.3","","344.45","344.45","344.45","1 through 10","420","658.98","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","1120.13","1120.13","1120.13","1 through 10","420","658.98","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","456.17","105.33","1284.66","242","420","658.98","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","464.71","67.87","1012.10","221","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","293.04","293.04","293.04","11","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","983.89","983.89","983.89","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","391.50","58","","677.18","677.18","677.18","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.88","62.5","","46.58","46.58","46.58","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","747.15","747.15","747.15","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","1141.67","481.21","1141.67","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","76.54","76.54","76.54","1 through 10","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","273.64","94.28","1367.51","138","300.04","525.89","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","720.78","230.14","2010.94","427","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.28","59.3","","344.45","344.45","344.45","1 through 10","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","1120.13","1120.13","1120.13","1 through 10","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","456.17","105.33","1284.66","242","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","464.71","67.87","1012.10","221","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","293.04","293.04","293.04","11","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","983.89","983.89","983.89","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","677.18","677.18","677.18","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","46.58","46.58","46.58","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","747.15","747.15","747.15","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","1141.67","481.21","1141.67","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","76.54","76.54","76.54","1 through 10","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","273.64","94.28","1367.51","138","320.04","560.95","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","720.78","230.14","2010.94","427","360","564.84","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","426.96","59.3","","344.45","344.45","344.45","1 through 10","360","564.84","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1120.13","1120.13","1120.13","1 through 10","360","564.84","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","456.17","105.33","1284.66","242","360","564.84","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","464.71","67.87","1012.10","221","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","293.04","293.04","293.04","11","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","983.89","983.89","983.89","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","826.50","58","","677.18","677.18","677.18","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","890.63","62.5","","46.58","46.58","46.58","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","747.15","747.15","747.15","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","1141.67","481.21","1141.67","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","76.54","76.54","76.54","1 through 10","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","273.64","94.28","1367.51","138","633.41","1110.22","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","720.78","230.14","2010.94","427","712.5","1117.91","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","845.03","59.3","","344.45","344.45","344.45","1 through 10","712.5","1117.91","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","1120.13","1120.13","1120.13","1 through 10","712.5","1117.91","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","456.17","105.33","1284.66","242","712.5","1117.91","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","AETNA [1001]","HB CH AETNA HMO / PPO","2053.33","58.3","","1530.90","1160.93","1884.08","89","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1866.66","53","","5253.92","5253.92","5253.92","1 through 10","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2042.76","58","","12181.47","12181.47","12181.47","1 through 10","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2201.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1565.53","44.45","","1910.74","891.94","1910.74","1 through 10","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","WELLPOINT [1015]","HB CH WELLPOINT","2743.99","77.91","","1829.79","1561.50","2617.12","88","1565.53","2743.99","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3522.00","2641.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2088.55","59.3","","1359.46","1201.30","1689.00","61","1761","2763.01","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3522.00","2641.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2088.55","59.3","","1718.92","1718.92","1718.92","1 through 10","1761","2763.01","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3522.00","2641.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2763.01","78.45","","1910.74","1019.06","2344.84","74","1761","2763.01","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB CH AETNA HMO / PPO","1068.64","58.3","","1530.90","1160.93","1884.08","89","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","971.49","53","","5253.92","5253.92","5253.92","1 through 10","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1063.14","58","","12181.47","12181.47","12181.47","1 through 10","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1145.63","62.5","","1350.68","1350.68","1350.68","1 through 10","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","814.77","44.45","","1910.74","891.94","1910.74","1 through 10","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","WELLPOINT [1015]","HB CH WELLPOINT","1428.09","77.91","","1829.79","1561.50","2617.12","88","814.77","1428.09","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1833.00","1374.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.97","59.3","","1359.46","1201.30","1689.00","61","916.5","1437.99","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1833.00","1374.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1086.97","59.3","","1718.92","1718.92","1718.92","1 through 10","916.5","1437.99","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1437.99","78.45","","1910.74","1019.06","2344.84","74","916.5","1437.99","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","AETNA [1001]","HB CH AETNA HMO / PPO","1000.43","58.3","","1530.90","1160.93","1884.08","89","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","909.48","53","","5253.92","5253.92","5253.92","1 through 10","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","995.28","58","","12181.47","12181.47","12181.47","1 through 10","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1072.50","62.5","","1350.68","1350.68","1350.68","1 through 10","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","762.76","44.45","","1910.74","891.94","1910.74","1 through 10","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","WELLPOINT [1015]","HB CH WELLPOINT","1336.94","77.91","","1829.79","1561.50","2617.12","88","762.76","1336.94","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.00","1287.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1017.59","59.3","","1359.46","1201.30","1689.00","61","858","1346.2","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.00","1287.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1017.59","59.3","","1718.92","1718.92","1718.92","1 through 10","858","1346.2","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.00","1287.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1346.20","78.45","","1910.74","1019.06","2344.84","74","858","1346.2","percent of total billed charges",""
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","47.00","35.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","30.70","34.68","1 through 10","24.91","99.43","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","30.70","34.68","1 through 10","25.97","99.43","other","OPPS APC"
"Annual Wellness Visit (PPS) Subseq","PX-51000135","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","273.36","273.36","273.36","1 through 10","28.88","484.04","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000139","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","273.36","273.36","273.36","1 through 10","28.88","484.04","percent of total billed charges",""
"Antepartum With O.R. Procedure,MAJOR","547","DRG","","","","","","","","inpatient","","","28357.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32769.20","","Standard inlier is a Case rate ($32,769.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $45,266, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,651.72) for the length of stay and the standard reimbursement.","32769.20","32769.20","32769.20","1 through 10","7195.76","35200.66","case rate",""
"Antepartum With O.R. Procedure,MINOR","547","DRG","","","","","","","","inpatient","","","28598.49","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16943.30","","Standard inlier is a Case rate ($16,943.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,405.03) for the length of stay and the standard reimbursement.","16943.29","16943.29","16943.29","1 through 10","7195.76","35200.66","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","28447.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22053.69","","Standard inlier is a Case rate ($22,053.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,130.61) for the length of stay and the standard reimbursement.","22053.69","22053.69","22053.69","1 through 10","7195.76","35200.66","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","28447.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23690.07","","Standard inlier is a Case rate ($23,690.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,362.70) for the length of stay and the standard reimbursement.","22613.24","22613.24","22613.24","1 through 10","7195.76","35200.66","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12063.83","","Standard inlier is a Case rate ($12,063.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,024, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,712.51) for the length of stay and the standard reimbursement.","12063.83","12063.83","19704.21","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12958.96","","Standard inlier is a Case rate ($12,958.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,024, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,839.47) for the length of stay and the standard reimbursement.","12958.96","12958.96","12958.96","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($15,428.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","10286.00","10286.00","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","16162.84","","Fee schedule rate ($16,162.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15539.52","15539.52","15539.52","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","7341.99","","Case rate ($7,909.83). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,339.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7577.54","7577.54","7577.54","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6421.98","","Fee schedule rate ($6,421.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6421.98","6421.98","6421.98","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","19115.21","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7341.99","","Case rate ($7,909.83). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,339.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7930.17","7930.17","7930.17","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","11764.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6160.62","","Standard inlier is a Case rate ($6,160.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $17,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($874.52) for the length of stay and the standard reimbursement.","5880.67","5880.67","6160.61","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","11764.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6617.73","","Standard inlier is a Case rate ($6,617.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $17,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($939.36) for the length of stay and the standard reimbursement.","6316.92","6316.92","6617.73","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","11764.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($7,339.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","7339.98","7339.98","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","11764.98","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($7,706.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","7706.92","7706.92","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8290.97","","Standard inlier is a Case rate ($8,290.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,176.94) for the length of stay and the standard reimbursement.","8290.97","1123.50","8290.97","11","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8906.16","","Standard inlier is a Case rate ($8,906.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,264.19) for the length of stay and the standard reimbursement.","8501.93","3792.57","8906.15","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($9,335.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","8975.50","8975.50","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($9,801.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","9801.92","9801.92","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","11668.78","","Fee schedule rate ($11,668.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8845.00","8845.00","8845.00","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10268.64","","Fee schedule rate ($10,268.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10268.64","10268.64","10268.64","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4504.18","","Fee schedule rate ($4,504.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4504.18","4504.18","4504.18","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9600.44","","Fee schedule rate ($9,600.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9600.44","9600.44","9600.44","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","13671.47","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","10163.3088","","Fee schedule rate ($10,268.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10163.3088","9872.63","9872.63","1 through 10","2937.47","24244.26","case rate",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","AETNA [1001]","HB CH AETNA HMO / PPO","85.70","58.3","","85.62","85.62","171.24","33","16.92","139.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","107.31","73","","85.62","85.62","85.62","1 through 10","16.92","139.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","TRICARE [160005]","HB NWH TRICARE","139.65","95","","20.81","20.81","20.81","1 through 10","16.92","139.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.34","44.45","","116.09","68.80","116.09","1 through 10","16.92","139.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.34","44.45","","68.80","68.80","68.80","1 through 10","16.92","139.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","147.00","110.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.17","59.3","","88.49","88.49","265.47","48","13.35","115.32","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","115.32","78.45","","116.09","68.80","116.09","29","13.35","115.32","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","14.75","122.55","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB CH AETNA HMO / PPO","59.47","58.3","","56.14","56.14","56.14","16","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","99.00","63.16","131.27","13","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","74.46","73","","198.00","198.00","198.00","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","63.16","63.16","63.16","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","WELLPOINT [1015]","HB CH WELLPOINT","79.47","77.91","","275.97","76.50","275.97","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","58.02","58.02","116.03","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","58.85","57.7","","59.70","59.70","59.70","21","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61.71","60.5","","62.67","62.67","125.33","14","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.02","78.45","","76.11","45.11","76.11","13","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB CH AETNA HMO / PPO","59.47","58.3","","56.14","56.14","56.14","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","131.27","131.27","131.27","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","58.02","58.02","58.02","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","58.85","57.7","","59.70","59.70","59.70","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61.71","60.5","","62.67","62.67","62.67","1 through 10","29.85","80.02","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","93","11.85","95.95","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB NWH TRICARE","95.95","95","","14.57","14.57","14.57","1 through 10","11.85","95.95","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.89","44.45","","75.34","75.34","75.34","1 through 10","11.85","95.95","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","92","12.46","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","1 through 10","12.46","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","44.65","75.34","84","12.46","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","11","10.94","95.95","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB NWH TRICARE","95.95","95","","13.45","13.45","13.45","1 through 10","10.94","95.95","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","172.29","13","11.5","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","44.65","75.34","14","11.5","79.23","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","64.00","48.00","AETNA [1001]","HB CH AETNA HMO / PPO","37.31","58.3","","35.15","35.15","35.15","1 through 10","7.15","60.8","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","64.00","48.00","TRICARE [160005]","HB NWH TRICARE","60.80","95","","8.80","8.80","8.80","1 through 10","7.15","60.8","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","64.00","48.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.95","59.3","","36.33","36.33","36.33","1 through 10","7.53","50.21","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.21","78.45","","47.67","47.67","47.67","1 through 10","7.53","50.21","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","113.00","84.75","AETNA [1001]","HB CH AETNA HMO / PPO","65.88","58.3","","62.37","62.37","62.37","1 through 10","11.61","107.35","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","113.00","84.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.01","59.3","","64.46","64.46","64.46","1 through 10","12.22","88.65","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.65","78.45","","84.57","50.12","84.57","1 through 10","12.22","88.65","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","95.00","71.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.34","59.3","","53.91","53.91","53.91","1 through 10","11.14","74.53","percent of total billed charges",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","206118.36","154588.77","MEDICARE [2001]","HB NWH MEDICARE","65520.27","","Case rate ($65,520.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $61,214.72, add-ons for qualifying new technology services are included. If operating cost exceeds $106,356.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,495.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $60,966.49. The transfer operating threshold is the transfer adjustment factor * $61,214.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,553.78. The transfer capital threshold is the transfer adjustment factor * $4,553.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","63751.12","63751.12","63751.12","1 through 10","58397.83","65935.8964","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","106698.32","80023.74","MEDICARE [2001]","HB NWH MEDICARE","40231.07","","Case rate ($40,231.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,587.35, add-ons for qualifying new technology services are included. If operating cost exceeds $82,729.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,738.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $37,434.93. The transfer operating threshold is the transfer adjustment factor * $37,587.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,796.13. The transfer capital threshold is the transfer adjustment factor * $2,796.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","39710.44","39710.44","39781.82","1 through 10","35857.71","41145.1623","other","Inpatient DRG"
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","61","20.67","122.55","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","129.00","96.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.17","73","","37.97","37.97","37.97","1 through 10","20.67","122.55","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","73.25","75","15.99","101.2","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.34","44.45","","96.10","56.95","96.10","1 through 10","15.99","101.2","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","96.10","56.95","96.10","48","15.99","101.2","percent of total billed charges",""
"Appendectomy With Complex Principal Diagnosis,MAJOR","233","DRG","","","","","","","","inpatient","","","29287.73","","MASSHEALTH [3001]","HB NWH MEDICAID","17627.85","","Case rate ($18,991.22). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $61,421.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19040.07","19040.07","19040.07","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy With Complex Principal Diagnosis,MAJOR","233","DRG","","","","","","","","inpatient","","","29287.73","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","17627.85","","Case rate ($18,991.22). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $61,421.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23800.08","23800.08","23800.08","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy With Complex Principal Diagnosis,MINOR","233","DRG","","","","","","","","inpatient","","","39726.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24527.26","","Standard inlier is a Case rate ($24,527.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,810, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,481.74) for the length of stay and the standard reimbursement.","24527.25","24527.25","24527.25","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy With Complex Principal Diagnosis,MINOR","233","DRG","","","","","","","","inpatient","","","39726.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26347.17","","Standard inlier is a Case rate ($26,347.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,810, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,739.87) for the length of stay and the standard reimbursement.","26347.16","26347.16","26347.16","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy With Complex Principal Diagnosis,MODERATE","233","DRG","","","","","","","","inpatient","","","47450.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34028.79","","Standard inlier is a Case rate ($34,028.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,146, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,830.24) for the length of stay and the standard reimbursement.","34028.79","34028.79","34028.79","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy With Complex Principal Diagnosis,MODERATE","233","DRG","","","","","","","","inpatient","","","47450.27","","MASSHEALTH [3001]","HB NWH MEDICAID","11149.49","","Case rate ($12,011.82). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,441.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5476.53","5476.53","12042.70","1 through 10","8821.35","49310.42","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MINOR","234","DRG","","","","","","","","inpatient","","","32975.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19891.47","","Standard inlier is a Case rate ($19,891.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,055, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,823.67) for the length of stay and the standard reimbursement.","19891.47","19891.47","19891.47","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MINOR","234","DRG","","","","","","","","inpatient","","","32975.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21367.41","","Standard inlier is a Case rate ($21,367.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,055, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,033.01) for the length of stay and the standard reimbursement.","20396.16","20396.16","20396.16","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MINOR","234","DRG","","","","","","","","inpatient","","","32975.84","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9067.99","","Fee schedule rate ($9,067.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9067.99","9067.99","9067.99","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","40898.53","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27598.03","","Standard inlier is a Case rate ($27,598.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,004, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,917.42) for the length of stay and the standard reimbursement.","26343.57","26343.57","26343.57","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","40898.53","","MASSHEALTH [3001]","HB NWH MEDICAID","7947.44","","Case rate ($8,562.11). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,992.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8584.13","8584.13","8584.13","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","40898.53","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","9747.54","","Fee schedule rate ($9,747.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9747.46","9747.46","9747.46","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy,MINOR","225","DRG","","","","","","","","inpatient","","","30681.35","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","15140.97","","Fee schedule rate ($15,140.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38841.82","38841.82","38841.82","1 through 10","11843.295","68963.47","case rate",""
"Appendectomy,MINOR","225","DRG","","","","","","","","inpatient","","","30681.35","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","15861.90","","Fee schedule rate ($15,861.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15861.90","15861.90","15861.90","1 through 10","11843.295","68963.47","case rate",""
"Appendectomy,MODERATE","225","DRG","","","","","","","","inpatient","","","40355.28","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","23032.58","","Fee schedule rate ($23,032.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24129.26","24129.26","24129.26","1 through 10","11843.295","68963.47","case rate",""
"Appendectomy,MODERATE","225","DRG","","","","","","","","inpatient","","","40355.28","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","24129.26","","Fee schedule rate ($24,129.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23813.72","23813.72","23813.72","1 through 10","11843.295","68963.47","case rate",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","42477.53","31858.15","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13113.71","","Case rate ($13,113.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,471.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,613.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,944.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,111.58. The transfer operating threshold is the transfer adjustment factor * $13,471.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,002.14. The transfer capital threshold is the transfer adjustment factor * $1,002.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13052.96","13052.96","13052.96","1 through 10","12851.44","14964.0348","other","Inpatient Replacement Plans DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","42477.53","31858.15","MEDICARE [2001]","HB NWH MEDICARE","13113.71","","Case rate ($13,113.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,471.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,613.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,944.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,111.58. The transfer operating threshold is the transfer adjustment factor * $13,471.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,002.14. The transfer capital threshold is the transfer adjustment factor * $1,002.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14442.23","14442.23","14468.20","1 through 10","12851.44","14964.0348","other","Inpatient Replacement Plans DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","42477.53","31858.15","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","12851.44","","Case rate ($13,113.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,471.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,613.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,944.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,111.58. The transfer operating threshold is the transfer adjustment factor * $13,471.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,002.14. The transfer capital threshold is the transfer adjustment factor * $1,002.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14588.45","14588.45","15073.24","1 through 10","12851.44","14964.0348","other","Inpatient DRG"
"Appendix Procedures With McC","397","MS-DRG","","","","","","","","inpatient","","","51586.66","38689.99","MEDICARE [2001]","HB NWH MEDICARE","22814.29","","Case rate ($22,814.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,315.10, add-ons for qualifying new technology services are included. If operating cost exceeds $66,457.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,527.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,228.67. The transfer operating threshold is the transfer adjustment factor * $21,315.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,585.64. The transfer capital threshold is the transfer adjustment factor * $1,585.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23691.06","23691.06","23691.06","1 through 10","20334.24","24583.65","other","Inpatient DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","34273.61","25705.21","MEDICARE [2001]","HB NWH MEDICARE","9917.60","","Case rate ($9,917.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,188.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,330.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,699.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,159.70. The transfer operating threshold is the transfer adjustment factor * $10,188.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.89. The transfer capital threshold is the transfer adjustment factor * $757.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6928.65","6928.65","6928.65","1 through 10","9719.25","11113.2582","other","Inpatient Replacement Plans DRG"
"Appl Cast Leg Short","PX-76000713","CDM","29405","CPT","0510","RC","","","","both","","","466.00","349.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","235.58","363.06","per diem",""
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","92.18","50.1","","142.89","142.89","142.89","1 through 10","90.29","567.68","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.81","23.81","23.81","1 through 10","22.26","39.94","percent of total billed charges",""
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","outpatient","","","337.00","252.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","199.84","59.3","","192.21","192.21","192.21","1 through 10","134.62","484.95","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","both","","","100.00","75.00","AETNA [1001]","HB CH AETNA HMO / PPO","58.30","58.3","","55.00","55.00","55.00","1 through 10","36.63","95.1","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","both","","","100.00","75.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","63.40","63.4","","64.31","64.31","64.31","1 through 10","36.63","95.1","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","inpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.60","70.6","","44.19","44.19","44.19","1 through 10","56","70.6","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","1 through 10","18.59","112.1","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","67.39","1 through 10","19.57","119.57","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","88.41","1 through 10","19.57","119.57","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","both","","","9886.00","7414.50","AETNA [1001]","HB CH AETNA HMO / PPO","5763.54","58.3","","4755.15","3387.26","4755.15","1 through 10","4241.09","7702.18","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","both","","","9886.00","7414.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,383). Procedure 2, Per diem ($2,691.50). Procedures 3 - 9999, Per diem ($1,345.75).","5383.00","1345.00","5383.00","1 through 10","4241.09","7702.18","per diem",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","both","","","9886.00","7414.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,653). Procedure 2, Per diem ($2,826.50). Procedures 3 - 9999, Per diem ($1,413.25).","5328.00","5328.00","5328.00","1 through 10","4241.09","7702.18","per diem",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","both","","","9886.00","7414.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","5934.00","5934.00","5934.00","1 through 10","4241.09","7702.18","per diem",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","both","","","9886.00","7414.50","WELLPOINT [1015]","HB CH WELLPOINT","7702.18","77.91","","7057.68","3291.40","7600.34","1 through 10","4241.09","7702.18","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","outpatient","","","9886.00","7414.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4851.06","49.07","","17691.79","17324.23","17691.79","1 through 10","3954.4","7755.57","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","outpatient","","","9886.00","7414.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4952.89","50.1","","17716.29","17348.73","17716.29","1 through 10","3954.4","7755.57","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","outpatient","","","9886.00","7414.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5862.40","59.3","","4693.42","2557.89","7852.65","1 through 10","3954.4","7755.57","percent of total billed charges",""
"Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc","PX-76000371","CDM","22552","CPT","0761","RC","","","","both","","","2276.00","1707.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,383). Procedure 2, Per diem ($2,691.50). Procedures 3 - 9999, Per diem ($1,345.75).","1345.00","1345.00","1345.00","1 through 10","976.4","1661.48","per diem",""
"Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc","PX-76000371","CDM","22552","CPT","0761","RC","","","","both","","","2276.00","1707.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,653). Procedure 2, Per diem ($2,826.50). Procedures 3 - 9999, Per diem ($1,413.25).","2664.00","2664.00","2664.00","1 through 10","976.4","1661.48","per diem",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","374.79","1 through 10","247.48","529.79","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","181.16","181.16","181.16","1 through 10","247.48","529.79","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","247.48","529.79","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","350.56","350.56","1 through 10","247.48","529.79","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","520.60","1 through 10","247.48","529.79","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","408.67","408.67","1 through 10","247.48","567.68","other","ASC "
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","400.74","409.23","1 through 10","247.48","567.68","other","ASC "
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","1 through 10","291.72","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","601.12","601.12","601.12","1 through 10","424.52","1055.88","other","ASC "
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-76002076","CDM","20606","CPT","0761","RC","","","","outpatient","","","259.00","194.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","990.18","990.18","1 through 10","115.13","684.77","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","AETNA [1001]","HB CH AETNA HMO / PPO","353.30","58.3","","333.96","333.96","333.96","1 through 10","247.48","472.13","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","247.48","472.13","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","700.37","331.16","727.59","1 through 10","247.48","472.13","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","236.00","236.00","236.00","1 through 10","247.48","472.13","per diem",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","242.00","270.00","1 through 10","247.48","472.13","per diem",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","345.13","323.26","350.56","15","247.48","472.13","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","400.74","400.74","400.74","1 through 10","247.48","567.68","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","606.00","454.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","359.36","59.3","","345.15","345.15","345.15","1 through 10","247.48","567.68","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","475.41","78.45","","452.82","268.35","452.83","1 through 10","247.48","567.68","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","1 through 10","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","613.01","613.01","613.01","1 through 10","259.97","1055.88","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","601.12","601.12","601.12","1 through 10","259.97","1055.88","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","AETNA [1001]","HB CH AETNA HMO / PPO","177.82","58.3","","168.40","168.40","168.40","1 through 10","135.57","361.04","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.83","361.83","361.83","1 through 10","135.57","361.04","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.26","323.26","323.26","1 through 10","135.57","361.04","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","135.57","361.04","per diem",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","135.57","361.04","per diem",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","349.49","322.74","349.49","1 through 10","135.57","361.04","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","305.00","228.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","336.09","336.09","336.09","1 through 10","152.5","567.68","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","239.27","78.45","","228.33","135.31","228.33","1 through 10","152.5","567.68","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","305.00","228.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","1 through 10","302.23","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","305.00","228.75","MEDICARE [2001]","HB NWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","302.23","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","outpatient","","","305.00","228.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","613.86","613.86","613.86","1 through 10","130.85","1055.88","other","ASC "
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","520.60","1 through 10","247.48","529.79","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","613.01","613.01","613.01","1 through 10","424.52","1055.88","other","ASC "
"Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt","PX-76002074","CDM","20604","CPT","0761","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","762.00","762.00","762.00","1 through 10","120.84","361.04","per diem",""
"Arthrod Pst Cmbn Tq Sgl Interspace","PX-76000372","CDM","22633","CPT","0761","RC","","","","both","","","8930.00","6697.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,383). Procedure 2, Per diem ($2,691.50). Procedures 3 - 9999, Per diem ($1,345.75).","5383.00","5226.00","5383.00","1 through 10","3830.97","6518.9","per diem",""
"Arthrod Pst Cmbn Tq Sgl Interspace","PX-76000372","CDM","22633","CPT","0761","RC","","","","both","","","8930.00","6697.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","17802.00","17802.00","17802.00","1 through 10","3830.97","6518.9","per diem",""
"Arthrodesis Post Cmbnd Tq Ea Addl","PX-76000373","CDM","22634","CPT","0761","RC","","","","both","","","2380.00","1785.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1487.50","62.5","","8999.02","8999.02","8999.02","1 through 10","1021.02","1854.26","percent of total billed charges",""
"Arthrodesis Post Cmbnd Tq Ea Addl","PX-76000373","CDM","22634","CPT","0761","RC","","","","both","","","2380.00","1785.00","WELLPOINT [1015]","HB CH WELLPOINT","1854.26","77.91","","4101.82","4101.82","4101.82","1 through 10","1021.02","1854.26","percent of total billed charges",""
"Arthrosc Aid Rpr Cruciate Lig Ant","PX-76001853","CDM","29888","CPT","0761","RC","","","","both","","","23058.00","17293.50","AETNA [1001]","HB CH AETNA HMO / PPO","13442.81","58.3","","7555.84","7555.84","7555.84","1 through 10","5129.63","16832.34","percent of total billed charges",""
"Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension","PX-98302528","CDM","25448","CPT","0983","RC","","","","both","","","4047.00","3035.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3775.72","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3784.01","3783.16","3784.01","1 through 10","1736.16","10869.44","other","OPPS APC"
"Asp Cyst Intervert Disc/Paravert","PX-76001459","CDM","62267","CPT","0761","RC","","","","both","","","1382.00","1036.50","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","1076.72","other","OPPS APC"
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","115.00","86.25","AETNA [1001]","HB CH AETNA HMO / PPO","67.05","58.3","","63.50","63.50","63.50","1 through 10","11.74","109.25","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","115.00","86.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.20","59.3","","65.63","65.63","65.63","1 through 10","11.81","90.22","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.22","78.45","","86.11","86.11","86.11","1 through 10","11.81","90.22","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","14.75","91.2","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","1 through 10","15.2","92.87","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","AETNA [1001]","HB CH AETNA HMO / PPO","309.57","58.3","","292.57","292.57","292.57","1 through 10","236.03","488.65","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","236.03","488.65","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","236.03","488.65","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","MEDICARE [2001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","355.85","474.47","13","236.03","488.65","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","236.03","488.65","per diem",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","WELLPOINT [1015]","HB CH WELLPOINT","413.70","77.91","","406.40","406.40","406.40","1 through 10","236.03","488.65","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","507.87","259.32","518.64","1 through 10","265.5","567.68","other","ASC "
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","519.36","508.58","519.36","15","265.5","567.68","other","ASC "
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","775.78","747.51","775.78","1 through 10","265.5","567.68","other","Multiple Surgery"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","747.51","747.51","747.51","1 through 10","265.5","567.68","other","Multiple Surgery"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","416.57","78.45","","235.09","235.09","235.09","1 through 10","265.5","567.68","percent of total billed charges",""
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2503.28","2503.28","2503.28","1 through 10","1565.78","3718.64","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","MEDICARE [2001]","HB NWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","23","1565.78","3718.64","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1565.78","3718.64","per diem",""
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2384.08","2384.08","2384.08","1 through 10","1565.78","3718.64","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","outpatient","","","4773.00","3579.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2813.15","2872.84","1 through 10","1565.78","3744.42","other","ASC "
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","outpatient","","","4773.00","3579.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2876.82","2817.13","2876.82","1 through 10","1565.78","3744.42","other","ASC "
"Aspiration Cath Nasotracheal","PX-76000806","CDM","31720","CPT","0761","RC","","","","outpatient","","","252.00","189.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","219.11","","Case rate ($219.11). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","309.82","309.82","309.82","1 through 10","126","1873.9","other","ASC "
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","AETNA [1001]","HB CH AETNA HMO / PPO","765.48","58.3","","724.06","724.06","724.06","1 through 10","579.34","1022.96","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","1 through 10","579.34","1022.96","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","206.55","206.55","206.55","1 through 10","579.34","1022.96","per diem",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","579.34","1022.96","per diem",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","579.34","1022.96","per diem",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","WELLPOINT [1015]","HB CH WELLPOINT","1022.96","77.91","","1005.77","1005.77","1005.77","1 through 10","579.34","1022.96","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","936.79","478.33","956.66","1 through 10","579.34","1030.05","other","ASC "
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","957.99","11","579.34","1030.05","other","ASC "
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","778.61","59.3","","748.32","748.32","748.32","1 through 10","579.34","1030.05","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2042.19","1361.45","2042.19","1 through 10","579.34","1030.05","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","4292.91","1430.97","4292.91","1 through 10","579.34","1030.05","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1030.05","78.45","","981.76","981.76","981.76","1 through 10","579.34","1030.05","percent of total billed charges",""
"Aspiration Cyst Breast Ea Add","PX-76000243","CDM","19001","CPT","0761","RC","","","","both","","","110.00","82.50","AETNA [1001]","HB CH AETNA HMO / PPO","64.13","58.3","","60.67","60.67","60.67","1 through 10","58.3","85.7","percent of total billed charges",""
"Aspiration Cyst Breast Ea Add","PX-76000243","CDM","19001","CPT","0761","RC","","","","both","","","110.00","82.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","103.28","103.28","103.28","1 through 10","58.3","85.7","per diem",""
"Aspiration Cyst Spinal Cord Perc","PX-76001460","CDM","62268","CPT","0761","RC","","","","outpatient","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1236.74","1236.74","1236.74","1 through 10","764.84","1873.9","other","ASC "
"Assay Lipoprotein Pla2","PX-30000554","CDM","83698","CPT","0301","RC","","","","both","","","395.00","296.25","AETNA [1001]","HB CH AETNA HMO / PPO","230.29","58.3","","217.73","217.73","217.73","1 through 10","45.38","375.25","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1197.00","897.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","939.05","78.45","","894.88","894.88","894.88","1 through 10","478.8","939.05","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","AETNA [1001]","HB CH AETNA HMO / PPO","192.97","58.3","","182.57","182.57","182.57","67","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","238.65","72.1","","242.79","242.79","242.79","1 through 10","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","209.85","63.4","","213.49","213.49","213.49","21","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","WELLPOINT [1015]","HB CH WELLPOINT","257.88","77.91","","253.61","253.61","253.61","1 through 10","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","162.42","49.07","","162.55","162.55","190.98","110","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","165.83","50.1","","250.93","250.93","250.93","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","165.83","50.1","","165.96","165.96","204.15","288","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","196.28","59.3","","188.69","188.69","188.69","45","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","190.99","57.7","","194.17","194.17","371.27","77","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","200.26","60.5","","203.83","203.83","389.94","33","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","200.26","60.5","","196.10","196.10","196.10","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","259.67","78.45","","247.55","146.70","247.55","36","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.13","44.45","","247.55","247.55","247.55","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Direct Measurement Free Estradiol","PX-30003730","CDM","82681","CPT","0301","RC","","","","both","","","233.00","174.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","147.72","63.4","","150.50","150.50","150.50","1 through 10","27.38","221.58","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.99","59.3","","82.63","82.63","82.63","1 through 10","43.11","113.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","89.25","89.25","89.25","1 through 10","43.11","113.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","108.40","108.40","1 through 10","43.11","113.75","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","14","14.03","143.45","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.23","73","","12.88","12.88","12.88","1 through 10","14.03","143.45","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","TRICARE [160005]","HB NWH TRICARE","143.45","95","","17.26","17.26","17.26","1 through 10","14.03","143.45","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.12","44.45","","113.01","66.00","113.01","1 through 10","14.03","143.45","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","107","13.35","118.46","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","66.97","113.02","24","13.35","118.46","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","AETNA [1001]","HB CH AETNA HMO / PPO","190.06","58.3","","179.74","179.74","179.74","253","27.38","309.7","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","TRICARE [160005]","HB NWH TRICARE","309.70","95","","33.67","31.99","33.67","1 through 10","27.38","309.7","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","309.70","95","","27.94","27.94","27.94","1 through 10","27.38","309.7","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.91","44.45","","243.71","142.33","243.71","1 through 10","27.38","309.7","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.91","44.45","","243.71","243.71","243.71","1 through 10","27.38","309.7","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","326.00","244.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.32","59.3","","185.76","185.76","185.76","225","28.81","255.75","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","255.75","78.45","","243.71","144.43","243.71","186","28.81","255.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","189.00","141.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","136.27","72.1","","138.74","138.74","138.74","1 through 10","21.73","179.74","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","189.00","141.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.08","59.3","","107.82","107.82","107.82","1 through 10","55.69","148.27","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","189.00","141.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","109.05","57.7","","554.75","110.95","554.75","1 through 10","55.69","148.27","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","189.00","141.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","114.35","60.5","","222.83","121.99","222.83","1 through 10","55.69","148.27","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","148.27","78.45","","141.46","141.46","141.46","1 through 10","55.69","148.27","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","1530.90","1160.93","1884.08","89","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","5253.92","5253.92","5253.92","1 through 10","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","139.20","58","","12181.47","12181.47","12181.47","1 through 10","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","150.00","62.5","","1350.68","1350.68","1350.68","1 through 10","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","1910.74","891.94","1910.74","1 through 10","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","1829.79","1561.50","2617.12","88","106.68","186.98","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","1359.46","1201.30","1689.00","61","120","188.28","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","142.32","59.3","","1718.92","1718.92","1718.92","1 through 10","120","188.28","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","1910.74","1019.06","2344.84","74","120","188.28","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","AETNA [1001]","HB CH AETNA HMO / PPO","4848.23","58.3","","1530.90","1160.93","1884.08","89","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4407.48","53","","5253.92","5253.92","5253.92","1 through 10","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4823.28","58","","12181.47","12181.47","12181.47","1 through 10","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5197.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3696.46","44.45","","1910.74","891.94","1910.74","1 through 10","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","WELLPOINT [1015]","HB CH WELLPOINT","6479.00","77.91","","1829.79","1561.50","2617.12","88","3696.46","6479","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4931.39","59.3","","1359.46","1201.30","1689.00","61","4158","6523.9","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4931.39","59.3","","1718.92","1718.92","1718.92","1 through 10","4158","6523.9","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6523.90","78.45","","1910.74","1019.06","2344.84","74","4158","6523.9","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","2190.90","412.50","9264.59","16","786.77","1379.01","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.60","58","","1903.20","1903.20","3826.66","1 through 10","786.77","1379.01","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.25","62.5","","2186.25","2186.25","2186.25","32","786.77","1379.01","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","5556.60","5556.60","5556.60","1 through 10","786.77","1379.01","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","1955.15","885.83","3150.40","26","786.77","1379.01","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","831.03","253.22","2394.88","18","885","1388.57","percent of total billed charges",""
"ASSEMBLY PLATE 38MM 2 LEVEL SPINE CETRA ANTERIOR CERVICAL","SUP-ITM-10188500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","2481.69","1563.74","8149.28","1 through 10","885","1388.57","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1005.00","753.75","AETNA [1001]","HB CH AETNA HMO / PPO","585.92","58.3","","2190.90","412.50","9264.59","16","446.72","783","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","582.90","58","","1903.20","1903.20","3826.66","1 through 10","446.72","783","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","628.13","62.5","","2186.25","2186.25","2186.25","32","446.72","783","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1005.00","753.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","5556.60","5556.60","5556.60","1 through 10","446.72","783","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1005.00","753.75","WELLPOINT [1015]","HB CH WELLPOINT","783.00","77.91","","1955.15","885.83","3150.40","26","446.72","783","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.97","59.3","","831.03","253.22","2394.88","18","502.5","788.42","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","2481.69","1563.74","8149.28","1 through 10","502.5","788.42","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","190","5.08","41.8","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","CHAMPVA [160001]","HB NWH TRICARE","41.80","95","","6.24","6.24","6.24","1 through 10","5.08","41.8","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32.12","73","","24.38","24.38","24.38","1 through 10","5.08","41.8","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","TRICARE [160005]","HB NWH TRICARE","41.80","95","","49.24","5.93","49.24","1 through 10","5.08","41.8","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","33.06","33.06","33.06","1 through 10","5.08","41.8","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","154","5.34","34.52","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","19.59","33.06","157","5.34","34.52","percent of total billed charges",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","25854.01","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","16145.14","","Fee schedule rate ($16,145.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16145.14","16145.14","16145.14","1 through 10","4054.03","32775.29","case rate",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","25854.01","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","32775.29","","Fee schedule rate ($32,775.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32775.29","32775.29","32775.29","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16410.34","","Standard inlier is a Case rate ($16,410.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,329.51) for the length of stay and the standard reimbursement.","15664.62","15664.62","15664.62","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17627.98","","Standard inlier is a Case rate ($17,627.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,502.22) for the length of stay and the standard reimbursement.","17627.97","17627.97","17627.97","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8442.144","","Fee schedule rate ($16,780.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8442.144","16780.72","16780.72","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8864.208","","Fee schedule rate ($17,619.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8864.208","17619.68","17619.68","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","MASSHEALTH [3001]","HB NWH MEDICAID","6503.49","","Case rate ($7,006.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,436.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8780.63","8780.63","8780.63","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","6503.49","","Case rate ($7,006.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,436.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8780.63","8780.63","8780.63","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","15909.80","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6503.49","","Case rate ($7,006.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,436.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7024.50","5532.43","7024.50","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9070.55","","Standard inlier is a Case rate ($9,070.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,953, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,287.60) for the length of stay and the standard reimbursement.","9070.55","8658.87","9070.55","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9743.58","","Standard inlier is a Case rate ($9,743.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,953, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,383.06) for the length of stay and the standard reimbursement.","9300.69","9300.69","9743.58","11","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8442.144","","Fee schedule rate ($8,442.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8442.144","8442.14","8442.14","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","9286.27","","Fee schedule rate ($9,286.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8928.16","8928.16","8928.16","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","MASSHEALTH [3001]","HB NWH MEDICAID","4097.67","","Case rate ($4,414.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,844.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5532.43","5532.43","5532.43","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","10165.76","","Fee schedule rate ($10,165.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10165.76","10165.76","10165.76","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","8864.208","","Fee schedule rate ($8,864.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8864.208","9286.27","9286.27","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","11324.00","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4097.67","","Case rate ($4,414.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,844.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5532.43","5532.43","5532.43","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","15199.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13645.05","","Standard inlier is a Case rate ($13,645.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,646, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,936.97) for the length of stay and the standard reimbursement.","13645.04","13645.04","13645.04","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","15199.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14657.50","","Standard inlier is a Case rate ($14,657.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,646, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,080.57) for the length of stay and the standard reimbursement.","14657.50","13991.25","14657.50","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","15199.34","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8864.208","","Fee schedule rate ($11,976.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8864.208","11515.24","11515.24","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","15199.34","","MASSHEALTH [3001]","HB NWH MEDICAID","5266.31","","Case rate ($5,673.61). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,103.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5688.20","5688.20","5688.20","1 through 10","4054.03","32775.29","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","15199.34","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5266.31","","Case rate ($5,673.61). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,103.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5688.21","5688.21","5688.21","1 through 10","4054.03","32775.29","case rate",""
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","26488.27","19866.20","MEDICARE [2001]","HB NWH MEDICARE","11399.05","","Case rate ($11,399.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,649.98, add-ons for qualifying new technology services are included. If operating cost exceeds $55,792.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,734.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,606.80. The transfer operating threshold is the transfer adjustment factor * $10,649.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.25. The transfer capital threshold is the transfer adjustment factor * $792.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7944.93","7944.93","7944.93","1 through 10","10159.91","11503.8737","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","23302.63","17476.97","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","5832.55","","Case rate ($5,832.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,991.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,133.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,387.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,386.84. The transfer operating threshold is the transfer adjustment factor * $5,991.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.72. The transfer capital threshold is the transfer adjustment factor * $445.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5798.34","5798.34","5798.34","1 through 10","5715.9","6649.3636","other","Inpatient Replacement Plans DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","23302.63","17476.97","MEDICARE [2001]","HB NWH MEDICARE","5832.55","","Case rate ($5,832.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,991.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,133.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,387.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,386.84. The transfer operating threshold is the transfer adjustment factor * $5,991.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.72. The transfer capital threshold is the transfer adjustment factor * $445.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6429.04","6417.50","6429.04","17","5715.9","6649.3636","other","Inpatient Replacement Plans DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","23302.63","17476.97","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","5715.90","","Case rate ($5,832.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,991.61, add-ons for qualifying new technology services are included. If operating cost exceeds $51,133.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,387.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,386.84. The transfer operating threshold is the transfer adjustment factor * $5,991.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $445.72. The transfer capital threshold is the transfer adjustment factor * $445.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5737.23","5737.23","5737.23","1 through 10","5715.9","6649.3636","other","Inpatient DRG"
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","496.00","372.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","291.77","291.77","291.77","1 through 10","176.45","567.68","other","ASC "
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","496.00","372.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","294.13","59.3","","3767.35","3767.35","3767.35","1 through 10","176.45","567.68","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","188.00","141.00","AETNA [1001]","HB CH AETNA HMO / PPO","109.60","58.3","","103.76","103.76","103.76","1 through 10","36.98","222.6","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","147.49","78.45","","140.69","140.69","140.69","1 through 10","36.98","222.6","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","188.00","141.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","111.48","59.3","","101.82","101.82","101.82","1 through 10","11.81","141.69","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","48196.22","36147.16","MEDICARE [2001]","HB NWH MEDICARE","17329.58","","Case rate ($17,329.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,802.19, add-ons for qualifying new technology services are included. If operating cost exceeds $62,944.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,266.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,005.28. The transfer operating threshold is the transfer adjustment factor * $17,802.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.31. The transfer capital threshold is the transfer adjustment factor * $1,324.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18820.15","18820.15","18853.99","1 through 10","16982.99","19500.1191","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","48196.22","36147.16","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","16982.99","","Case rate ($17,329.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,802.19, add-ons for qualifying new technology services are included. If operating cost exceeds $62,944.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,266.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,005.28. The transfer operating threshold is the transfer adjustment factor * $17,802.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.31. The transfer capital threshold is the transfer adjustment factor * $1,324.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15670.24","15670.24","15670.24","1 through 10","16982.99","19500.1191","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","48196.22","36147.16","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16982.99","","Case rate ($17,329.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,802.19, add-ons for qualifying new technology services are included. If operating cost exceeds $62,944.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,266.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,005.28. The transfer operating threshold is the transfer adjustment factor * $17,802.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.31. The transfer capital threshold is the transfer adjustment factor * $1,324.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16829.23","16829.23","16829.23","1 through 10","16982.99","19500.1191","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","","","","inpatient","","","75308.52","56481.39","MEDICARE [2001]","HB NWH MEDICARE","32379.69","","Case rate ($32,379.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,262.74, add-ons for qualifying new technology services are included. If operating cost exceeds $78,405.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,416.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,905.27. The transfer operating threshold is the transfer adjustment factor * $33,262.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,474.42. The transfer capital threshold is the transfer adjustment factor * $2,474.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34267.81","34267.81","34267.81","1 through 10","31732.1","35442.176","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator","518","TRIS-DRG","","","","","","","","inpatient","","","46561.52","","TRICARE [160005]","HB NWH TRICARE","28152.24","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($39,471.10). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $12,334.72, and the first day is paid a rate of $44,404.99. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $24,669.44, and the first day is paid a rate of $49,338.88. The transfer payment is capped at $35,591.62. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $83,292.55 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 1.60000002384186) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 1.60000002384186). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($28,193.65), capped at $35,591.62. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $12,334.72, and the first day is paid a rate of $44,404.99. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $24,669.44, and the first day is paid a rate of $49,338.88. The transfer payment is capped at $35,591.62. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $83,292.55 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 1.60000002384186) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 1.60000002384186). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","30430.07","30430.07","30430.07","1 through 10","28152.24","28152.24","other","Inpatient DRGs"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","50577.03","37932.77","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13331.32","","Case rate ($12,943.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,296.02, add-ons for qualifying new technology services are included. If operating cost exceeds $58,438.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,931.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,953.95. The transfer operating threshold is the transfer adjustment factor * $13,296.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.09. The transfer capital threshold is the transfer adjustment factor * $989.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12862.81","12862.81","12862.81","1 through 10","12684.17","14172.9148","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","50577.03","37932.77","MEDICARE [2001]","HB NWH MEDICARE","12943.03","","Case rate ($12,943.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,296.02, add-ons for qualifying new technology services are included. If operating cost exceeds $58,438.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,931.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,953.95. The transfer operating threshold is the transfer adjustment factor * $13,296.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.09. The transfer capital threshold is the transfer adjustment factor * $989.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13703.30","13703.30","13703.30","1 through 10","12684.17","14172.9148","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","50577.03","37932.77","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12684.17","","Case rate ($12,943.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,296.02, add-ons for qualifying new technology services are included. If operating cost exceeds $58,438.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,931.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,953.95. The transfer operating threshold is the transfer adjustment factor * $13,296.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.09. The transfer capital threshold is the transfer adjustment factor * $989.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12216.49","12216.49","12216.49","1 through 10","12684.17","14172.9148","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With McC","094","MS-DRG","","","","","","","","inpatient","","","66577.60","49933.20","MEDICARE [2001]","HB NWH MEDICARE","30491.82","","Case rate ($30,491.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,323.38, add-ons for qualifying new technology services are included. If operating cost exceeds $76,465.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,272.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $28,161.67. The transfer operating threshold is the transfer adjustment factor * $31,323.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,330.15. The transfer capital threshold is the transfer adjustment factor * $2,330.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8833.24","8833.24","8833.24","1 through 10","29881.98","36126.64","other","Inpatient Replacement Plans DRG"
"Bacterial And Tuberculous Infections Of Nervous System,MAJOR","049","DRG","","","","","","","","inpatient","","","66577.60","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","26088.57","","Per diem ($6,402). If length of stay < 10, first 1 days paid at a per diem of $12,804 instead.","26088.57","12804.70","12804.70","1 through 10","2537","88540.17","per diem","Estimated amount calculated based on 1 day length of stay."
"Bacterial And Tuberculous Infections Of Nervous System,MAJOR","049","DRG","","","","","","","","inpatient","","","66577.60","","MASSHEALTH [3001]","HB NWH MEDICAID","19963.99","","Case rate ($21,508.05). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,938.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,196.94 and the sum of the standard inlier and any outlier amount.","21563.36","21563.36","21563.36","1 through 10","2537","88540.17","case rate",""
"Bacterial And Tuberculous Infections Of Nervous System,MODERATE","049","DRG","","","","","","","","inpatient","","","99310.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","44203.00","","Standard inlier is a Case rate ($44,203.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,996, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,274.79) for the length of stay and the standard reimbursement.","44202.99","44202.99","44202.99","1 through 10","2537","88540.17","case rate",""
"Bacterial And Tuberculous Infections Of Nervous System,MODERATE","049","DRG","","","","","","","","inpatient","","","99310.25","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","14430.37","","Case rate ($15,546.44). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,976.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,587.99 and the sum of the standard inlier and any outlier amount.","37970.21","37970.21","37970.21","1 through 10","2537","88540.17","case rate",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1315.57","49.07","","1257.55","1257.55","1257.55","1 through 10","1315.57","7178","percent of total billed charges",""
"BALLOON SINUS 6X17MM DILATION NUVENT EM SEEKER","SUP-ITM-10209199","CDM","C1726","HCPCS","0272","RC","","","","both","","","876.96","657.72","WELLPOINT [1015]","HB CH WELLPOINT","683.24","77.91","","582.67","582.67","582.67","1 through 10","389.81","683.24","percent of total billed charges",""
"BALLOON SINUS 6X17MM DILATION NUVENT EM SEEKER","SUP-ITM-10209199","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","876.96","657.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","687.98","78.45","","394.74","331.66","1115.07","1 through 10","438.48","687.98","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","AETNA [1001]","HB CH AETNA HMO / PPO","1880.18","58.3","","2190.90","412.50","9264.59","16","1433.51","2512.6","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1870.50","58","","1903.20","1903.20","3826.66","1 through 10","1433.51","2512.6","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2015.63","62.5","","2186.25","2186.25","2186.25","32","1433.51","2512.6","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2354.25","73","","5556.60","5556.60","5556.60","1 through 10","1433.51","2512.6","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","WELLPOINT [1015]","HB CH WELLPOINT","2512.60","77.91","","1955.15","885.83","3150.40","26","1433.51","2512.6","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1912.43","59.3","","831.03","253.22","2394.88","18","1612.5","2530.01","percent of total billed charges",""
"BAND VERSATIE 5.5MM PET MALLEABLE END","SUP-ITM-10250660","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2530.01","78.45","","2481.69","1563.74","8149.28","1 through 10","1612.5","2530.01","percent of total billed charges",""
"BARRIER ADHESION 3.0X4.0IN INTERCEED ABSORBABLE GYNECARE IMPLANTABLE BX/10EA","SUP-ITM-10074846","CDM","C1765","HCPCS","0278","RC","","","","outpatient","","","871.40","653.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","683.61","78.45","","669.93","397.01","758.05","1 through 10","435.7","683.61","percent of total billed charges",""
"BARRIER ADHESION 6X5IN SZ 1 SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/10EA","SUP-ITM-10002948","CDM","C1765","HCPCS","0278","RC","","","","outpatient","","","986.02","739.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","773.53","78.45","","669.93","397.01","758.05","1 through 10","493.01","773.53","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","82.00","61.50","AETNA [1001]","HB CH AETNA HMO / PPO","47.81","58.3","","45.36","45.36","45.36","1 through 10","9.98","77.9","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","64.33","78.45","","61.51","61.51","61.51","1 through 10","10.07","64.33","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","AETNA [1001]","HB CH AETNA HMO / PPO","2012.81","58.3","","1530.90","1160.93","1884.08","89","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1829.83","53","","5253.92","5253.92","5253.92","1 through 10","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2002.45","58","","12181.47","12181.47","12181.47","1 through 10","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2157.81","62.5","","1350.68","1350.68","1350.68","1 through 10","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.64","44.45","","1910.74","891.94","1910.74","1 through 10","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","WELLPOINT [1015]","HB CH WELLPOINT","2689.84","77.91","","1829.79","1561.50","2617.12","88","1534.64","2689.84","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2047.33","59.3","","1359.46","1201.30","1689.00","61","1726.25","2708.49","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2047.33","59.3","","1718.92","1718.92","1718.92","1 through 10","1726.25","2708.49","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2708.49","78.45","","1910.74","1019.06","2344.84","74","1726.25","2708.49","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","AETNA [1001]","HB CH AETNA HMO / PPO","4426.25","58.3","","1530.90","1160.93","1884.08","89","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4023.87","53","","5253.92","5253.92","5253.92","1 through 10","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4403.48","58","","12181.47","12181.47","12181.47","1 through 10","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4745.13","62.5","","1350.68","1350.68","1350.68","1 through 10","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3374.73","44.45","","1910.74","891.94","1910.74","1 through 10","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","both","","","7592.20","5694.15","WELLPOINT [1015]","HB CH WELLPOINT","5915.08","77.91","","1829.79","1561.50","2617.12","88","3374.73","5915.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7592.20","5694.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","4502.17","59.3","","1359.46","1201.30","1689.00","61","3796.1","5956.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7592.20","5694.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4502.17","59.3","","1718.92","1718.92","1718.92","1 through 10","3796.1","5956.08","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 1 TRIATHLON REVISION","SUP-ITM-10322134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7592.20","5694.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5956.08","78.45","","1910.74","1019.06","2344.84","74","3796.1","5956.08","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.88","56","","55.67","52.53","55.67","1 through 10","54.88","69.19","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.19","70.6","","73.04","43.28","218.00","1 through 10","54.88","69.19","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","912","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","CHAMPVA [160001]","HB NWH TRICARE","93.10","95","","10.19","10.19","10.19","1 through 10","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.94","53","","50.35","50.35","50.35","1 through 10","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","71.54","73","","54.34","51.88","54.34","1 through 10","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","TRICARE [160005]","HB NWH TRICARE","93.10","95","","10.19","9.68","10.19","16","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.56","44.45","","69.76","43.28","73.04","29","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.56","44.45","","43.28","43.28","73.04","1 through 10","8.29","93.1","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","101.03","1022","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","58.11","59.3","","54.34","54.34","54.34","1 through 10","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","95.00","73.04","95.00","1 through 10","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","43.28","73.04","748","8.73","76.88","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","519.00","389.25","AETNA [1001]","HB CH AETNA HMO / PPO","302.58","58.3","","286.34","286.34","286.34","1 through 10","115.31","493.05","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","115.31","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($117.66). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($91.91). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","115.81","115.81","115.81","1 through 10","115.31","493.05","fee schedule",""
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","14432.09","10824.07","MEDICARE [2001]","HB NWH MEDICARE","6877.91","","Case rate ($6,877.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,425.94, add-ons for qualifying new technology services are included. If operating cost exceeds $51,568.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,420.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,399.89. The transfer operating threshold is the transfer adjustment factor * $6,425.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.03. The transfer capital threshold is the transfer adjustment factor * $478.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7117.45","7104.68","7117.45","1 through 10","6130.24","7411.33","other","Inpatient DRG"
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","130.00","97.50","AETNA [1001]","HB CH AETNA HMO / PPO","75.79","58.3","","71.44","71.44","142.88","20","24.94","150.17","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","130.00","97.50","TRICARE [160005]","HB NWH TRICARE","123.50","95","","252.00","252.00","252.00","1 through 10","24.94","150.17","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","130.00","97.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.09","59.3","","73.84","73.84","73.84","17","14.19","101.99","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.99","78.45","","96.87","57.41","96.87","14","14.19","101.99","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","74.28","1 through 10","15.86","128.25","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.77","76.77","76.77","1 through 10","16.68","105.91","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","100.71","100.71","100.71","1 through 10","16.68","105.91","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","both","","","22.05","16.54","AETNA [1001]","HB CH AETNA HMO / PPO","12.86","58.3","","12.50","12.50","19.09","1 through 10","11.69","20.33","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1671.00","1253.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1589.12","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1671.00","1253.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","837.17","50.1","","2255.00","204.62","2255.00","1 through 10","567.68","1310.9","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","1733.64","1733.64","1733.64","1 through 10","567.68","1310.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1043.00","782.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","991.89","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1043.00","782.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","522.54","50.1","","2255.00","204.62","2255.00","1 through 10","463.61","818.23","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1043.00","782.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","818.23","78.45","","1733.64","1733.64","1733.64","1 through 10","463.61","818.23","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","145.00","108.75","AETNA [1001]","HB CH AETNA HMO / PPO","84.54","58.3","","79.95","79.95","79.95","15","16.78","137.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","145.00","108.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.99","59.3","","82.63","82.63","82.63","18","17.66","113.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","64.24","108.40","1 through 10","17.66","113.75","percent of total billed charges",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC","410","MS-DRG","","","","","","","","inpatient","","","79726.41","59794.81","MEDICARE [2001]","HB NWH MEDICARE","13755.71","","Case rate ($13,755.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,130.86, add-ons for qualifying new technology services are included. If operating cost exceeds $59,273.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,993.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,704.52. The transfer operating threshold is the transfer adjustment factor * $14,130.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.20. The transfer capital threshold is the transfer adjustment factor * $1,051.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14803.97","14803.97","14803.97","1 through 10","13480.6","15338.8279","other","Inpatient Replacement Plans DRG"
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.81","76","4.92","40.85","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","CHAMPVA [160001]","HB NWH TRICARE","40.85","95","","6.05","6.05","6.05","1 through 10","4.92","40.85","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","31.39","73","","29.93","29.93","29.93","1 through 10","4.92","40.85","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","TRICARE [160005]","HB NWH TRICARE","40.85","95","","48.05","5.75","48.05","1 through 10","4.92","40.85","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","40.85","95","","5.02","5.02","5.02","1 through 10","4.92","40.85","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.50","59.3","","24.61","24.61","24.61","73","5.18","33.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.73","78.45","","32.29","19.14","32.29","66","5.18","33.73","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","51.00","38.25","AETNA [1001]","HB CH AETNA HMO / PPO","29.73","58.3","","28.35","28.35","28.35","50","4.92","48.45","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","51.00","38.25","CHAMPVA [160001]","HB NWH TRICARE","48.45","95","","6.05","6.05","6.05","1 through 10","4.92","48.45","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","51.00","38.25","TRICARE [160005]","HB NWH TRICARE","48.45","95","","56.05","5.75","56.05","1 through 10","4.92","48.45","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","51.00","38.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","48.45","95","","5.02","5.02","5.02","1 through 10","4.92","48.45","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.67","44.45","","38.44","38.44","38.44","1 through 10","4.92","48.45","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","51.00","38.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.24","59.3","","29.30","29.30","29.30","43","5.18","40.01","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.01","78.45","","38.44","22.78","38.44","26","5.18","40.01","percent of total billed charges",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","52587.07","39440.30","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","20880.19","","Case rate ($21,306.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,887.38, add-ons for qualifying new technology services are included. If operating cost exceeds $67,029.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,570.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,678.12. The transfer operating threshold is the transfer adjustment factor * $21,887.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,628.21. The transfer capital threshold is the transfer adjustment factor * $1,628.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19967.60","19967.60","19967.60","1 through 10","20880.19","23126.4154","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","72247.49","54185.62","MEDICARE [2001]","HB NWH MEDICARE","32909.23","","Case rate ($32,909.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $30,746.65, add-ons for qualifying new technology services are included. If operating cost exceeds $75,888.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,229.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,621.97. The transfer operating threshold is the transfer adjustment factor * $30,746.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,287.25. The transfer capital threshold is the transfer adjustment factor * $2,287.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27649.97","27649.97","27649.97","1 through 10","29331.8","34008.271","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC","479","MS-DRG","","","","","","","","inpatient","","","29758.18","22318.63","MEDICARE [2001]","HB NWH MEDICARE","17708.26","","Case rate ($17,708.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,544.59, add-ons for qualifying new technology services are included. If operating cost exceeds $61,686.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,172.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,477.50. The transfer operating threshold is the transfer adjustment factor * $16,544.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,230.76. The transfer capital threshold is the transfer adjustment factor * $1,230.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13609.50","13609.50","13609.50","1 through 10","15783.26","17708.26","other","Inpatient DRG"
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3775.00","3775.00","3775.00","1 through 10","1873.9","3745.99","other","ASC "
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3860.43","3860.43","3860.43","1 through 10","1873.9","3745.99","other","ASC "
"Biopsy Bone Open Superficial","PX-76000278","CDM","20240","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2925.84","50.1","","1925.56","1925.56","1925.56","1 through 10","2336","4581.48","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","3854.00","2890.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3002.65","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2227.31","2227.31","2227.31","1 through 10","1237.95","4472.66","other","ASC "
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","AETNA [1001]","HB CH AETNA HMO / PPO","371.95","58.3","","351.54","351.54","4687.96","1 through 10","165.93","497.07","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","600.44","413.17","669.54","1 through 10","165.93","497.07","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","MEDICARE [2001]","HB NWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","217.48","238.90","1 through 10","165.93","497.07","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","165.93","497.07","per diem",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","810.00","1 through 10","165.93","497.07","per diem",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","465.74","73","","597.27","597.27","597.27","1 through 10","165.93","497.07","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","638.00","478.50","WELLPOINT [1015]","HB CH WELLPOINT","497.07","77.91","","1108.31","488.31","1108.31","1 through 10","165.93","497.07","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","274.00","268.31","274.00","12","165.93","567.68","other","ASC "
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","268.69","268.69","274.38","17","165.93","567.68","other","ASC "
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","378.33","59.3","","1251.69","363.32","1251.69","1 through 10","165.93","567.68","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","389.94","389.94","389.94","1 through 10","165.93","567.68","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","487.83","487.83","487.83","1 through 10","165.93","567.68","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","500.51","78.45","","476.66","282.47","476.66","1 through 10","165.93","567.68","percent of total billed charges",""
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2359.00","1769.25","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","1837.9","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1850.64","78.45","","1763.63","1763.63","1763.63","1 through 10","579.34","1873.9","percent of total billed charges",""
"Biopsy Intranasal","PX-76000743","CDM","30100","CPT","0761","RC","","","","both","","","1930.00","1447.50","AETNA [1001]","HB CH AETNA HMO / PPO","1125.19","58.3","","4687.96","4687.96","4687.96","1 through 10","73.06","1723.75","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1240.00","930.00","AETNA [1001]","HB CH AETNA HMO / PPO","722.92","58.3","","683.80","683.80","683.80","1 through 10","558.04","1064.97","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1240.00","930.00","MEDICARE [2001]","HB NWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","558.04","1064.97","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1240.00","930.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","4523.00","4523.00","4523.00","1 through 10","558.04","1064.97","per diem",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","972.78","78.45","","927.17","927.17","927.17","1 through 10","551.18","972.78","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","AETNA [1001]","HB CH AETNA HMO / PPO","1218.47","58.3","","1152.14","1152.14","1152.14","1 through 10","929.01","1981.66","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","929.01","1981.66","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3206.29","3206.29","3206.29","1 through 10","929.01","1981.66","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","5772.39","18","929.01","1981.66","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","929.01","1981.66","per diem",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","929.01","1981.66","per diem",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1525.70","73","","1152.14","1152.14","1152.14","1 through 10","929.01","1981.66","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.45","1891.05","1893.45","1 through 10","929.01","1981.66","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","929.01","44.45","","925.78","925.78","925.78","1 through 10","929.01","1981.66","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1889.50","1889.50","1 through 10","929.01","1981.66","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","WELLPOINT [1015]","HB CH WELLPOINT","1628.32","77.91","","1580.85","1580.85","1580.85","1 through 10","929.01","1981.66","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2224.17","2224.17","2271.35","11","1045","1873.9","other","ASC "
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2227.31","2274.50","1 through 10","1045","1873.9","other","ASC "
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8393.31","5595.54","8727.54","11","1045","1873.9","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","9173.22","3057.74","9173.22","1 through 10","1045","1873.9","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1639.61","78.45","","1562.20","1562.20","1562.20","1 through 10","1045","1873.9","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","918.78","1981.66","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","3639.57","3639.57","3639.57","1 through 10","918.78","1981.66","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","962.07","1924.13","12","918.78","1981.66","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5680.35","1893.05","5680.35","1 through 10","918.78","1981.66","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","918.78","1981.66","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2271.35","2271.35","2271.35","1 through 10","1033.5","1873.9","other","ASC "
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2227.31","2274.50","1 through 10","1033.5","1873.9","other","ASC "
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","8393.31","8727.54","1 through 10","1033.5","1873.9","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3639.57","3057.74","3639.57","1 through 10","1033.5","1873.9","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1621.56","78.45","","1545.29","1545.29","1545.29","1 through 10","1033.5","1873.9","percent of total billed charges",""
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","1240.00","930.00","MEDICARE [2001]","HB NWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","531.96","1064.97","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1378.36","1378.36","1378.36","1 through 10","558.04","1873.9","other","Multiple Surgery"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","972.78","78.45","","927.17","927.17","927.17","1 through 10","558.04","1873.9","percent of total billed charges",""
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","131.40","131.40","131.40","1 through 10","1713.1","7178","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2089.00","1566.75","AETNA [1001]","HB CH AETNA HMO / PPO","1217.89","58.3","","1151.58","1151.58","1151.58","1 through 10","928.56","1981.66","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2089.00","1566.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","928.56","1981.66","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2089.00","1566.75","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","5772.39","13","928.56","1981.66","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2089.00","1566.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.65","1887.65","1887.65","1 through 10","928.56","1981.66","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2227.31","4549.00","1 through 10","1044.5","1873.9","other","ASC "
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1238.78","59.3","","1190.17","1190.17","1190.17","1 through 10","1044.5","1873.9","percent of total billed charges",""
"Biopsy Muscle Superficial","PX-76000273","CDM","20200","CPT","0761","RC","","","","outpatient","","","4063.00","3047.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2035.56","50.1","","1137.25","1137.25","1137.25","1 through 10","1625.2","3187.42","percent of total billed charges",""
"Biopsy Renal Needle Perc","PX-76001222","CDM","50200","CPT","0761","RC","","","","both","","","2202.00","1651.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1894.65","1894.65","1894.65","1 through 10","978.79","1981.66","other","OPPS APC"
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","both","","","1382.00","1036.50","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","1076.72","other","OPPS APC"
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","outpatient","","","1382.00","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","956.66","956.66","956.66","1 through 10","579.34","1084.18","other","ASC "
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","outpatient","","","1382.00","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","938.11","1 through 10","579.34","1084.18","other","ASC "
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","7889.00","5916.75","MEDICARE [2001]","HB NWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6419.59","6419.59","6419.59","1 through 10","3938.87","6611.51","other","OPPS APC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","7889.00","5916.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6293.20","6293.20","6293.20","1 through 10","3938.87","6611.51","other","OPPS APC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","7889.00","5916.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6298.20","6298.20","6298.20","1 through 10","3938.87","6611.51","other","OPPS APC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","7889.00","5916.75","WELLPOINT [1015]","HB CH WELLPOINT","6146.32","77.91","","6041.68","6041.68","6041.68","1 through 10","3938.87","6611.51","percent of total billed charges",""
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","7889.00","5916.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5004.80","","Case rate ($5,004.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7236.94","7236.94","7236.94","1 through 10","1873.9","6188.92","other","ASC "
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","7889.00","5916.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3938.87","","Case rate ($3,938.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","27769.02","27769.02","27769.02","1 through 10","1873.9","6188.92","other","Multiple Surgery"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1240.00","930.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","558.04","1064.97","per diem",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","902.34","902.34","902.34","1 through 10","551.18","1873.9","other","ASC "
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3934.17","3934.17","3934.17","1 through 10","551.18","1873.9","other","Multiple Surgery"
"Biopsy/Exc Lymph Node Axil Deep","PX-76001208","CDM","38525","CPT","0361","RC","","","","both","","","6816.00","5112.00","AETNA [1001]","HB CH AETNA HMO / PPO","3973.73","58.3","","6766.58","6766.58","6766.58","1 through 10","2924.06","5310.35","percent of total billed charges",""
"Biopsy/Exc Lymph Node Cerv Deep","PX-76001207","CDM","38510","CPT","0361","RC","","","","both","","","6816.00","5112.00","WELLPOINT [1015]","HB CH WELLPOINT","5310.35","77.91","","17659.70","17659.70","17659.70","1 through 10","2924.06","5310.35","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","2090.00","1567.50","AETNA [1001]","HB CH AETNA HMO / PPO","1218.47","58.3","","2304.28","2304.28","2304.29","1 through 10","929.01","1981.66","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","2090.00","1567.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1892.55","1893.55","1 through 10","929.01","1981.66","other","OPPS APC"
"Biopsy/Exc Node Lymph Open Super","PX-76001205","CDM","38500","CPT","0361","RC","","","","both","","","6816.00","5112.00","AETNA [1001]","HB CH AETNA HMO / PPO","3973.73","58.3","","11202.78","11202.78","11202.78","1 through 10","2924.06","5310.35","percent of total billed charges",""
"Biotinidase Ea Specimen","PX-30000327","CDM","82261","CPT","0301","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","90.72","90.72","1 through 10","11.02","94.92","percent of total billed charges",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27939.75","","Standard inlier is a Case rate ($27,939.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,966.16) for the length of stay and the standard reimbursement.","12404.00","12404.00","12404.00","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30012.86","","Standard inlier is a Case rate ($30,012.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,260.20) for the length of stay and the standard reimbursement.","27360.00","9120.00","70520.00","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15561.29","","Fee schedule rate ($15,561.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67620.00","67620.00","67620.00","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","MASSHEALTH [3001]","HB NWH MEDICAID","12606.01","","Case rate ($13,580.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,010.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4772.95","431.45","13475.49","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","12606.01","","Case rate ($13,580.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,010.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8532.13","8532.13","8532.13","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5158.62","","Fee schedule rate ($5,158.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1200.48","1200.48","1200.48","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","12606.01","","Case rate ($13,580.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,010.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","350.00","350.00","17759.08","1 through 10","886.93","52244.95","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","34651.27","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","12606.01","","Case rate ($13,580.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,010.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","884.01","884.01","884.01","1 through 10","886.93","52244.95","case rate",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","AETNA [1001]","HB CH AETNA HMO / PPO","100.31","58.3","","1530.90","1160.93","1884.08","89","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.19","53","","5253.92","5253.92","5253.92","1 through 10","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","99.79","58","","12181.47","12181.47","12181.47","1 through 10","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","107.53","62.5","","1350.68","1350.68","1350.68","1 through 10","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.48","44.45","","1910.74","891.94","1910.74","1 through 10","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.05","129.04","WELLPOINT [1015]","HB CH WELLPOINT","134.04","77.91","","1829.79","1561.50","2617.12","88","76.48","134.04","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.05","129.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.03","59.3","","1359.46","1201.30","1689.00","61","86.03","134.97","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.05","129.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.03","59.3","","1718.92","1718.92","1718.92","1 through 10","86.03","134.97","percent of total billed charges",""
"BIT DRILL 2X85MM SS JACOBS CHUCK QUICK CONNECT","SUP-ITM-10041352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.05","129.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.97","78.45","","1910.74","1019.06","2344.84","74","86.03","134.97","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","AETNA [1001]","HB CH AETNA HMO / PPO","219.08","58.3","","464.71","67.87","1012.10","221","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","219.08","58.3","","293.04","293.04","293.04","11","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","199.16","53","","983.89","983.89","983.89","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","217.95","58","","677.18","677.18","677.18","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","234.86","62.5","","46.58","46.58","46.58","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","274.32","73","","747.15","747.15","747.15","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.03","44.45","","1141.67","481.21","1141.67","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.03","44.45","","76.54","76.54","76.54","1 through 10","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.78","281.83","WELLPOINT [1015]","HB CH WELLPOINT","292.77","77.91","","273.64","94.28","1367.51","138","167.03","292.77","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.78","281.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.84","59.3","","720.78","230.14","2010.94","427","187.89","294.8","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.78","281.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","222.84","59.3","","344.45","344.45","344.45","1 through 10","187.89","294.8","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.78","281.83","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","294.80","78.45","","1120.13","1120.13","1120.13","1 through 10","187.89","294.8","percent of total billed charges",""
"BIT DRILL 3X2.1MM ASNIS MICRO SOLID","SUP-ITM-10101162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.78","281.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.80","78.45","","456.17","105.33","1284.66","242","187.89","294.8","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","AETNA [1001]","HB CH AETNA HMO / PPO","808.27","58.3","","464.71","67.87","1012.10","221","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","808.27","58.3","","293.04","293.04","293.04","11","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","734.79","53","","983.89","983.89","983.89","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","804.11","58","","677.18","677.18","677.18","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","866.49","62.5","","46.58","46.58","46.58","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","747.15","747.15","747.15","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","1141.67","481.21","1141.67","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","76.54","76.54","76.54","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","WELLPOINT [1015]","HB CH WELLPOINT","1080.14","77.91","","273.64","94.28","1367.51","138","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","822.13","59.3","","720.78","230.14","2010.94","427","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","822.13","59.3","","344.45","344.45","344.45","1 through 10","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","1120.13","1120.13","1120.13","1 through 10","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X130MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","456.17","105.33","1284.66","242","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","AETNA [1001]","HB CH AETNA HMO / PPO","808.27","58.3","","464.71","67.87","1012.10","221","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","808.27","58.3","","293.04","293.04","293.04","11","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","734.79","53","","983.89","983.89","983.89","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","804.11","58","","677.18","677.18","677.18","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","866.49","62.5","","46.58","46.58","46.58","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","747.15","747.15","747.15","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","1141.67","481.21","1141.67","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","76.54","76.54","76.54","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","WELLPOINT [1015]","HB CH WELLPOINT","1080.14","77.91","","273.64","94.28","1367.51","138","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","822.13","59.3","","720.78","230.14","2010.94","427","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","822.13","59.3","","344.45","344.45","344.45","1 through 10","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","1120.13","1120.13","1120.13","1 through 10","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","456.17","105.33","1284.66","242","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","AETNA [1001]","HB CH AETNA HMO / PPO","808.27","58.3","","1530.90","1160.93","1884.08","89","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","734.79","53","","5253.92","5253.92","5253.92","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","804.11","58","","12181.47","12181.47","12181.47","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","866.49","62.5","","1350.68","1350.68","1350.68","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","1910.74","891.94","1910.74","1 through 10","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","WELLPOINT [1015]","HB CH WELLPOINT","1080.14","77.91","","1829.79","1561.50","2617.12","88","616.25","1080.14","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","822.13","59.3","","1359.46","1201.30","1689.00","61","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","822.13","59.3","","1718.92","1718.92","1718.92","1 through 10","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","1910.74","1019.06","2344.84","74","693.2","1087.62","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1710.00","1282.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1014.03","59.3","","1002.06","1002.06","1002.06","1 through 10","760.1","1341.5","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1710.00","1282.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1341.50","78.45","","1026.35","1026.35","1026.35","1 through 10","760.1","1341.5","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1002.06","1002.06","1002.06","1 through 10","593.41","1047.31","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1026.35","1026.35","1026.35","1 through 10","593.41","1047.31","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1002.06","1002.06","1002.06","1 through 10","1000.13","1765.13","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","1026.35","1026.35","1026.35","1 through 10","1000.13","1765.13","percent of total billed charges",""
"Blepharoplasty Upper Excess Skin|BILATERAL PROCEDURE","PX-76000201","CDM","15823","CPT","0761","RC","","","50","both","","","4610.00","3457.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2396.11","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3359.97","3359.97","3359.97","1 through 10","2063.7","9038.18","other","OPPS APC"
"Blepharoplasty Upper Excess Skin|BILATERAL PROCEDURE","PX-76000201","CDM","15823","CPT","0761","RC","","","50","both","","","4610.00","3457.50","MEDICARE [2001]","HB NWH MEDICARE","2326.32","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3258.48","3258.48","3258.48","1 through 10","2063.7","9038.18","other","OPPS APC"
"Blepharoplasty Upper Excess Skin|BILATERAL PROCEDURE","PX-76000201","CDM","15823","CPT","0761","RC","","","50","both","","","4610.00","3457.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2279.79","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3200.71","3194.31","3200.71","1 through 10","2063.7","9038.18","other","OPPS APC"
"Blepharoplasty Upper Excess Skin|BILATERAL PROCEDURE","PX-76000201","CDM","15823","CPT","0761","RC","","","50","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2656.98","","Case rate ($2,656.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3836.68","3836.68","3836.68","1 through 10","2656.98","14767.25","other","ASC "
"Blepharoplasty Upper Excess Skin|BILATERAL PROCEDURE","PX-76000201","CDM","15823","CPT","0761","RC","","","50","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2656.98","","Case rate ($2,656.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3762.28","3762.28","3762.28","1 through 10","2656.98","14767.25","other","ASC "
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1530.90","1160.93","1884.08","89","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","5253.92","5253.92","5253.92","1 through 10","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2283.75","58","","12181.47","12181.47","12181.47","1 through 10","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2460.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.22","44.45","","1910.74","891.94","1910.74","1 through 10","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","1829.79","1561.50","2617.12","88","1750.22","3067.71","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1359.46","1201.30","1689.00","61","1968.75","3088.97","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1718.92","1718.92","1718.92","1 through 10","1968.75","3088.97","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SIZE D 19","SUP-ITM-10012027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","1910.74","1019.06","2344.84","74","1968.75","3088.97","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","AETNA [1001]","HB CH AETNA HMO / PPO","857.62","58.3","","1530.90","1160.93","1884.08","89","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.66","53","","5253.92","5253.92","5253.92","1 through 10","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","853.21","58","","12181.47","12181.47","12181.47","1 through 10","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","919.41","62.5","","1350.68","1350.68","1350.68","1 through 10","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.88","44.45","","1910.74","891.94","1910.74","1 through 10","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","WELLPOINT [1015]","HB CH WELLPOINT","1146.10","77.91","","1829.79","1561.50","2617.12","88","653.88","1146.1","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1471.05","1103.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","872.33","59.3","","1359.46","1201.30","1689.00","61","735.53","1154.04","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1471.05","1103.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","872.33","59.3","","1718.92","1718.92","1718.92","1 through 10","735.53","1154.04","percent of total billed charges",""
"BLOCK AUGMENT 67.5X5MM KNEE FEMORAL VANGUARD 360 POSTERIOR 10 UNIVERSAL","SUP-ITM-10117756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1471.05","1103.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1154.04","78.45","","1910.74","1019.06","2344.84","74","735.53","1154.04","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","AETNA [1001]","HB CH AETNA HMO / PPO","1232.26","58.3","","1530.90","1160.93","1884.08","89","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1120.23","53","","5253.92","5253.92","5253.92","1 through 10","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1225.92","58","","12181.47","12181.47","12181.47","1 through 10","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1321.03","62.5","","1350.68","1350.68","1350.68","1 through 10","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","939.52","44.45","","1910.74","891.94","1910.74","1 through 10","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","both","","","2113.65","1585.24","WELLPOINT [1015]","HB CH WELLPOINT","1646.74","77.91","","1829.79","1561.50","2617.12","88","939.52","1646.74","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2113.65","1585.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","1253.39","59.3","","1359.46","1201.30","1689.00","61","1056.83","1658.16","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2113.65","1585.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1253.39","59.3","","1718.92","1718.92","1718.92","1 through 10","1056.83","1658.16","percent of total billed charges",""
"BLOCK FEMORAL 20MM SIZE 13/15 IMPLANT HIP TO15 CEMENTED REVISION CALCAR 05A 33 CS/1BX/1EA","SUP-ITM-10019777","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2113.65","1585.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1658.16","78.45","","1910.74","1019.06","2344.84","74","1056.83","1658.16","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","464.71","67.87","1012.10","221","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","293.04","293.04","293.04","11","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","983.89","983.89","983.89","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","677.18","677.18","677.18","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","46.58","46.58","46.58","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","747.15","747.15","747.15","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","1141.67","481.21","1141.67","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","76.54","76.54","76.54","1 through 10","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","273.64","94.28","1367.51","138","60.01","105.18","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","720.78","230.14","2010.94","427","67.5","105.91","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","344.45","344.45","344.45","1 through 10","67.5","105.91","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1120.13","1120.13","1120.13","1 through 10","67.5","105.91","percent of total billed charges",""
"BLOCK SPINE REDUCTION","SUP-ITM-10089874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","456.17","105.33","1284.66","242","67.5","105.91","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.08","56","","52.74","49.76","52.74","1 through 10","52.08","65.66","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.66","70.6","","69.19","41.00","414.00","1 through 10","52.08","65.66","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","AETNA [1001]","HB CH AETNA HMO / PPO","54.22","58.3","","51.03","51.03","51.03","1283","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","67.89","73","","65.70","65.70","65.70","1 through 10","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","49.29","53","","47.70","31.27","47.70","1 through 10","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","67.89","73","","49.07","49.06","65.70","20","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","TRICARE [160005]","HB NWH TRICARE","88.35","95","","9.36","8.89","9.36","24","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.34","44.45","","41.00","40.41","69.19","35","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.34","44.45","","41.00","41.00","69.19","1 through 10","7.61","88.35","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","52.74","1338","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","52.74","1 through 10","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","69.19","90.00","1 through 10","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","41.00","69.19","1075","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0300","RC","","","","inpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.00","56","","42.78","40.36","42.78","1 through 10","42","52.95","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0300","RC","","","","inpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","52.95","70.6","","33.26","33.26","33.26","1 through 10","42","52.95","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","1550","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","CHAMPVA [160001]","HB NWH TRICARE","71.25","95","","7.80","7.80","7.80","1 through 10","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","53.29","53.29","53.29","1 through 10","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","1 through 10","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","41.39","11.76","42.78","16","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","TRICARE [160005]","HB NWH TRICARE","71.25","95","","7.80","7.41","7.80","23","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","71.25","95","","6.47","6.47","6.47","1 through 10","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","56.12","33.26","56.12","57","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","33.26","33.26","56.12","1 through 10","6.34","71.25","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","71.74","1527","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","41.76","41.76","41.76","1 through 10","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","53.84","73.00","1 through 10","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","33.26","56.12","1341","6.67","58.84","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","26.00","19.50","AETNA [1001]","HB CH AETNA HMO / PPO","15.16","58.3","","14.18","14.18","14.18","24","2.32","24.7","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","26.00","19.50","TRICARE [160005]","HB NWH TRICARE","24.70","95","","2.86","2.72","2.86","1 through 10","2.32","24.7","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","26.00","19.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","15.42","59.3","","14.65","14.65","14.65","17","2.44","20.4","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","26.00","19.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","20.40","78.45","","19.22","11.39","19.22","23","2.44","20.4","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","27.00","20.25","AETNA [1001]","HB CH AETNA HMO / PPO","15.74","58.3","","14.74","14.74","14.74","1 through 10","2.32","25.65","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","27.00","20.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","16.01","59.3","","15.24","15.24","15.24","1 through 10","2.44","21.18","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","both","","","24.00","18.00","TRICARE [160005]","HB NWH TRICARE","22.80","95","","3.06","3.06","3.06","1 through 10","2.49","22.8","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","24.00","18.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14.23","59.3","","65.05","13.48","65.05","1 through 10","2.61","18.83","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","29.48","29.48","29.48","1 through 10","4.39","50.35","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","53.00","39.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","38.69","73","","28.20","28.19","28.20","1 through 10","4.39","50.35","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","53.00","39.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.43","59.3","","30.47","30.47","30.47","1 through 10","4.61","41.58","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","32","3.91","39.9","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","42.00","31.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","30.66","73","","29.93","29.93","29.93","1 through 10","3.91","39.9","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","72.09","28","4.12","32.95","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","15.72","31.52","28","4.12","32.95","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","204.00","153.00","AETNA [1001]","HB CH AETNA HMO / PPO","118.93","58.3","","112.27","112.27","112.27","1 through 10","25.55","193.8","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","204.00","153.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.97","59.3","","194.38","116.03","424.65","15","19.95","160.04","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.04","78.45","","198.00","152.22","198.00","1 through 10","19.95","160.04","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0300","RC","","","","inpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.04","56","","19.34","19.34","19.34","1 through 10","19.04","24","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","27","3.72","32.3","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","34.00","25.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.82","73","","18.04","5.84","18.04","1 through 10","3.72","32.3","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","34.00","25.50","TRICARE [160005]","HB NWH TRICARE","32.30","95","","4.58","4.58","4.58","1 through 10","3.72","32.3","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.11","44.45","","24.27","24.27","24.27","1 through 10","3.72","32.3","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","99.00","25","3.54","26.67","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","34.00","25.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","25.37","25.37","1 through 10","3.54","26.67","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","15.03","25.37","27","3.54","26.67","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","167.00","125.25","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.40","35.60","106.80","38","15.15","1456.11","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","139.00","104.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.69","29.69","29.69","13","15.1","1456.11","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","139.00","104.25","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.18","28.48","35.60","40","15.1","1456.11","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","79.11","1 through 10","3.95","926.86","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0300","RC","","","","inpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.64","56","","53.33","53.33","53.33","1 through 10","52.64","66.36","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0300","RC","","","","inpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","66.36","70.6","","69.96","41.46","69.96","1 through 10","52.64","66.36","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB CH AETNA HMO / PPO","54.80","58.3","","51.60","51.60","51.60","263","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","157.65","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.52","157.52","158.16","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","MEDICARE [2001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","115","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","68.62","73","","49.63","49.63","51.60","1 through 10","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","TRICARE [160005]","HB NWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","153.08","91.00","153.08","1 through 10","11.83","565.41","other","Tricare OPPS"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","450.06","150.02","450.06","25","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.78","44.45","","69.96","41.46","69.96","1 through 10","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","153.08","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.74","59.3","","53.33","53.33","159.99","233","3.08","359.9","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","41.46","69.96","193","3.08","359.9","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","AETNA [1001]","HB CH AETNA HMO / PPO","1827.71","58.3","","2190.90","412.50","9264.59","16","1393.51","2442.48","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1818.30","58","","1903.20","1903.20","3826.66","1 through 10","1393.51","2442.48","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1959.38","62.5","","2186.25","2186.25","2186.25","32","1393.51","2442.48","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2288.55","73","","5556.60","5556.60","5556.60","1 through 10","1393.51","2442.48","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","WELLPOINT [1015]","HB CH WELLPOINT","2442.48","77.91","","1955.15","885.83","3150.40","26","1393.51","2442.48","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1859.06","59.3","","831.03","253.22","2394.88","18","1567.5","2459.41","percent of total billed charges",""
"BOLT GRAFT 8.5X25MM IDENTITI ALIF","SUP-ITM-10318949","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2459.41","78.45","","2481.69","1563.74","8149.28","1 through 10","1567.5","2459.41","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","AETNA [1001]","HB CH AETNA HMO / PPO","820.28","58.3","","464.71","67.87","1012.10","221","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","820.28","58.3","","293.04","293.04","293.04","11","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","745.71","53","","983.89","983.89","983.89","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","816.06","58","","677.18","677.18","677.18","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","879.38","62.5","","46.58","46.58","46.58","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1027.11","73","","747.15","747.15","747.15","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.41","44.45","","1141.67","481.21","1141.67","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.41","44.45","","76.54","76.54","76.54","1 through 10","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","WELLPOINT [1015]","HB CH WELLPOINT","1096.19","77.91","","273.64","94.28","1367.51","138","625.41","1096.19","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","834.35","59.3","","720.78","230.14","2010.94","427","703.5","1103.79","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","834.35","59.3","","344.45","344.45","344.45","1 through 10","703.5","1103.79","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1103.79","78.45","","1120.13","1120.13","1120.13","1 through 10","703.5","1103.79","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1103.79","78.45","","456.17","105.33","1284.66","242","703.5","1103.79","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","AETNA [1001]","HB CH AETNA HMO / PPO","414.51","58.3","","464.71","67.87","1012.10","221","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","414.51","58.3","","293.04","293.04","293.04","11","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","376.83","53","","983.89","983.89","983.89","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","412.38","58","","677.18","677.18","677.18","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","444.38","62.5","","46.58","46.58","46.58","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","519.03","73","","747.15","747.15","747.15","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","1141.67","481.21","1141.67","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","76.54","76.54","76.54","1 through 10","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","WELLPOINT [1015]","HB CH WELLPOINT","553.94","77.91","","273.64","94.28","1367.51","138","316.04","553.94","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.62","59.3","","720.78","230.14","2010.94","427","355.5","557.78","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","421.62","59.3","","344.45","344.45","344.45","1 through 10","355.5","557.78","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","1120.13","1120.13","1120.13","1 through 10","355.5","557.78","percent of total billed charges",""
"BOLT VARIABLE 50X225MM TITANIUM BASE","SUP-ITM-10191026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","456.17","105.33","1284.66","242","355.5","557.78","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","AETNA [1001]","HB CH AETNA HMO / PPO","330.56","58.3","","464.71","67.87","1012.10","221","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","330.56","58.3","","293.04","293.04","293.04","11","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","300.51","53","","983.89","983.89","983.89","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","328.86","58","","677.18","677.18","677.18","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","354.38","62.5","","46.58","46.58","46.58","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","413.91","73","","747.15","747.15","747.15","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.03","44.45","","1141.67","481.21","1141.67","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.03","44.45","","76.54","76.54","76.54","1 through 10","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.00","425.25","WELLPOINT [1015]","HB CH WELLPOINT","441.75","77.91","","273.64","94.28","1367.51","138","252.03","441.75","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.00","425.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","336.23","59.3","","720.78","230.14","2010.94","427","283.5","444.81","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.00","425.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","336.23","59.3","","344.45","344.45","344.45","1 through 10","283.5","444.81","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.00","425.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","444.81","78.45","","1120.13","1120.13","1120.13","1 through 10","283.5","444.81","percent of total billed charges",""
"BONE CEMENT ANTIBIOTIC REFOBACIN","SUP-ITM-10211829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","444.81","78.45","","456.17","105.33","1284.66","242","283.5","444.81","percent of total billed charges",""
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","30945.45","23209.09","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11567.98","","Case rate ($11,231.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,537.34, add-ons for qualifying new technology services are included. If operating cost exceeds $56,679.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,800.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,372.78. The transfer operating threshold is the transfer adjustment factor * $11,537.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.27. The transfer capital threshold is the transfer adjustment factor * $858.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11728.37","11728.37","11728.37","1 through 10","11006.43","12915.034","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","30945.45","23209.09","MEDICARE [2001]","HB NWH MEDICARE","12348.82","","Case rate ($12,348.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,537.34, add-ons for qualifying new technology services are included. If operating cost exceeds $56,679.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,800.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,490.55. The transfer operating threshold is the transfer adjustment factor * $11,537.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.27. The transfer capital threshold is the transfer adjustment factor * $858.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12464.70","12464.70","12487.09","1 through 10","11006.43","12915.034","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","30945.45","23209.09","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11006.43","","Case rate ($11,231.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,537.34, add-ons for qualifying new technology services are included. If operating cost exceeds $56,679.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,800.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,372.78. The transfer operating threshold is the transfer adjustment factor * $11,537.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.27. The transfer capital threshold is the transfer adjustment factor * $858.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11139.62","11139.62","11139.62","1 through 10","11006.43","12915.034","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","21370.97","16028.23","MEDICARE [2001]","HB NWH MEDICARE","7907.71","","Case rate ($7,907.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,388.06, add-ons for qualifying new technology services are included. If operating cost exceeds $52,530.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,491.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,358.10. The transfer operating threshold is the transfer adjustment factor * $7,388.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.60. The transfer capital threshold is the transfer adjustment factor * $549.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7965.55","502.16","7979.88","27","7048.09","8520.98","other","Inpatient DRG"
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","AETNA [1001]","HB CH AETNA HMO / PPO","4194.10","58.3","","1530.90","1160.93","1884.08","89","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3812.82","53","","5253.92","5253.92","5253.92","1 through 10","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4172.52","58","","12181.47","12181.47","12181.47","1 through 10","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4496.25","62.5","","1350.68","1350.68","1350.68","1 through 10","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3197.73","44.45","","1910.74","891.94","1910.74","1 through 10","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","both","","","7194.00","5395.50","WELLPOINT [1015]","HB CH WELLPOINT","5604.85","77.91","","1829.79","1561.50","2617.12","88","3197.73","5604.85","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7194.00","5395.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4266.04","59.3","","1359.46","1201.30","1689.00","61","3597","5643.69","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7194.00","5395.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4266.04","59.3","","1718.92","1718.92","1718.92","1 through 10","3597","5643.69","percent of total billed charges",""
"BONE HEAD 10X22MM RADIAL ELBOW COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC LEFT","SUP-ITM-10045144","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7194.00","5395.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5643.69","78.45","","1910.74","1019.06","2344.84","74","3597","5643.69","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","AETNA [1001]","HB CH AETNA HMO / PPO","4785.26","58.3","","1530.90","1160.93","1884.08","89","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4350.24","53","","5253.92","5253.92","5253.92","1 through 10","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4760.64","58","","12181.47","12181.47","12181.47","1 through 10","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5130.00","62.5","","1350.68","1350.68","1350.68","1 through 10","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3648.46","44.45","","1910.74","891.94","1910.74","1 through 10","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","WELLPOINT [1015]","HB CH WELLPOINT","6394.85","77.91","","1829.79","1561.50","2617.12","88","3648.46","6394.85","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4867.34","59.3","","1359.46","1201.30","1689.00","61","4104","6439.18","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4867.34","59.3","","1718.92","1718.92","1718.92","1 through 10","4104","6439.18","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6439.18","78.45","","1910.74","1019.06","2344.84","74","4104","6439.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","AETNA [1001]","HB CH AETNA HMO / PPO","2178.24","58.3","","464.71","67.87","1012.10","221","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.24","58.3","","293.04","293.04","293.04","11","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.22","53","","983.89","983.89","983.89","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.03","58","","677.18","677.18","677.18","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.16","62.5","","46.58","46.58","46.58","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","747.15","747.15","747.15","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","1141.67","481.21","1141.67","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","76.54","76.54","76.54","1 through 10","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","WELLPOINT [1015]","HB CH WELLPOINT","2910.92","77.91","","273.64","94.28","1367.51","138","1660.77","2910.92","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2215.60","59.3","","720.78","230.14","2010.94","427","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2215.60","59.3","","344.45","344.45","344.45","1 through 10","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","456.17","105.33","1284.66","242","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"BONE NAIL 330X10MM TIBIAL CANNULATED EX TI","SUP-ITM-10018660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","AETNA [1001]","HB CH AETNA HMO / PPO","385.04","58.3","","464.71","67.87","1012.10","221","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","385.04","58.3","","293.04","293.04","293.04","11","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","350.04","53","","983.89","983.89","983.89","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","383.06","58","","677.18","677.18","677.18","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","412.78","62.5","","46.58","46.58","46.58","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","482.13","73","","747.15","747.15","747.15","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.57","44.45","","1141.67","481.21","1141.67","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.57","44.45","","76.54","76.54","76.54","1 through 10","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","WELLPOINT [1015]","HB CH WELLPOINT","514.56","77.91","","273.64","94.28","1367.51","138","293.57","514.56","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.65","59.3","","720.78","230.14","2010.94","427","330.23","518.12","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","391.65","59.3","","344.45","344.45","344.45","1 through 10","330.23","518.12","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","518.12","78.45","","1120.13","1120.13","1120.13","1 through 10","330.23","518.12","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","518.12","78.45","","456.17","105.33","1284.66","242","330.23","518.12","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","AETNA [1001]","HB CH AETNA HMO / PPO","2078.91","58.3","","464.71","67.87","1012.10","221","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2078.91","58.3","","293.04","293.04","293.04","11","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1889.92","53","","983.89","983.89","983.89","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2068.21","58","","677.18","677.18","677.18","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2228.68","62.5","","46.58","46.58","46.58","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.09","73","","747.15","747.15","747.15","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.03","44.45","","1141.67","481.21","1141.67","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.03","44.45","","76.54","76.54","76.54","1 through 10","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","WELLPOINT [1015]","HB CH WELLPOINT","2778.18","77.91","","273.64","94.28","1367.51","138","1585.03","2778.18","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","2114.57","59.3","","720.78","230.14","2010.94","427","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2114.57","59.3","","344.45","344.45","344.45","1 through 10","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2797.43","78.45","","1120.13","1120.13","1120.13","1 through 10","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2797.43","78.45","","456.17","105.33","1284.66","242","1782.94","2797.43","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","AETNA [1001]","HB CH AETNA HMO / PPO","185.01","58.3","","464.71","67.87","1012.10","221","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.01","58.3","","293.04","293.04","293.04","11","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.19","53","","983.89","983.89","983.89","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.06","58","","677.18","677.18","677.18","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.34","62.5","","46.58","46.58","46.58","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","231.66","73","","747.15","747.15","747.15","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.06","44.45","","1141.67","481.21","1141.67","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.06","44.45","","76.54","76.54","76.54","1 through 10","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","WELLPOINT [1015]","HB CH WELLPOINT","247.24","77.91","","273.64","94.28","1367.51","138","141.06","247.24","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.18","59.3","","720.78","230.14","2010.94","427","158.67","248.95","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.18","59.3","","344.45","344.45","344.45","1 through 10","158.67","248.95","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","248.95","78.45","","1120.13","1120.13","1120.13","1 through 10","158.67","248.95","percent of total billed charges",""
"BONE PIN 1.8MM 14 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.95","78.45","","456.17","105.33","1284.66","242","158.67","248.95","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","AETNA [1001]","HB CH AETNA HMO / PPO","233.61","58.3","","464.71","67.87","1012.10","221","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","233.61","58.3","","293.04","293.04","293.04","11","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.38","53","","983.89","983.89","983.89","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","232.41","58","","677.18","677.18","677.18","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","250.44","62.5","","46.58","46.58","46.58","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","747.15","747.15","747.15","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.12","44.45","","1141.67","481.21","1141.67","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.12","44.45","","76.54","76.54","76.54","1 through 10","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","WELLPOINT [1015]","HB CH WELLPOINT","312.19","77.91","","273.64","94.28","1367.51","138","178.12","312.19","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.62","59.3","","720.78","230.14","2010.94","427","200.36","314.36","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","237.62","59.3","","344.45","344.45","344.45","1 through 10","200.36","314.36","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","314.36","78.45","","1120.13","1120.13","1120.13","1 through 10","200.36","314.36","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.36","78.45","","456.17","105.33","1284.66","242","200.36","314.36","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","AETNA [1001]","HB CH AETNA HMO / PPO","660.07","58.3","","464.71","67.87","1012.10","221","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","660.07","58.3","","293.04","293.04","293.04","11","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","600.07","53","","983.89","983.89","983.89","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","656.68","58","","677.18","677.18","677.18","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","707.63","62.5","","46.58","46.58","46.58","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","747.15","747.15","747.15","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","1141.67","481.21","1141.67","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","76.54","76.54","76.54","1 through 10","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","WELLPOINT [1015]","HB CH WELLPOINT","882.10","77.91","","273.64","94.28","1367.51","138","503.26","882.1","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","671.39","59.3","","720.78","230.14","2010.94","427","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","671.39","59.3","","344.45","344.45","344.45","1 through 10","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","1120.13","1120.13","1120.13","1 through 10","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","456.17","105.33","1284.66","242","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","AETNA [1001]","HB CH AETNA HMO / PPO","539.71","58.3","","464.71","67.87","1012.10","221","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","539.71","58.3","","293.04","293.04","293.04","11","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","490.64","53","","983.89","983.89","983.89","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","536.93","58","","677.18","677.18","677.18","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","578.59","62.5","","46.58","46.58","46.58","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","675.79","73","","747.15","747.15","747.15","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.49","44.45","","1141.67","481.21","1141.67","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.49","44.45","","76.54","76.54","76.54","1 through 10","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.74","694.30","WELLPOINT [1015]","HB CH WELLPOINT","721.24","77.91","","273.64","94.28","1367.51","138","411.49","721.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.74","694.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","548.96","59.3","","720.78","230.14","2010.94","427","462.87","726.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.74","694.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","548.96","59.3","","344.45","344.45","344.45","1 through 10","462.87","726.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.74","694.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","726.24","78.45","","1120.13","1120.13","1120.13","1 through 10","462.87","726.24","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.74","694.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","726.24","78.45","","456.17","105.33","1284.66","242","462.87","726.24","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","AETNA [1001]","HB CH AETNA HMO / PPO","602.48","58.3","","464.71","67.87","1012.10","221","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","602.48","58.3","","293.04","293.04","293.04","11","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","547.71","53","","983.89","983.89","983.89","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","599.38","58","","677.18","677.18","677.18","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","645.88","62.5","","46.58","46.58","46.58","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","754.39","73","","747.15","747.15","747.15","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.35","44.45","","1141.67","481.21","1141.67","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.35","44.45","","76.54","76.54","76.54","1 through 10","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","WELLPOINT [1015]","HB CH WELLPOINT","805.13","77.91","","273.64","94.28","1367.51","138","459.35","805.13","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","612.81","59.3","","720.78","230.14","2010.94","427","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","612.81","59.3","","344.45","344.45","344.45","1 through 10","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","810.71","78.45","","1120.13","1120.13","1120.13","1 through 10","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE 7 STAINLESS VARIABLE ANGLE LOCKING Y SHAPE","SUP-ITM-10164624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","810.71","78.45","","456.17","105.33","1284.66","242","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","AETNA [1001]","HB CH AETNA HMO / PPO","526.12","58.3","","464.71","67.87","1012.10","221","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.12","58.3","","293.04","293.04","293.04","11","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.29","53","","983.89","983.89","983.89","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","523.41","58","","677.18","677.18","677.18","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","564.02","62.5","","46.58","46.58","46.58","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","658.77","73","","747.15","747.15","747.15","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.13","44.45","","1141.67","481.21","1141.67","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.13","44.45","","76.54","76.54","76.54","1 through 10","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","WELLPOINT [1015]","HB CH WELLPOINT","703.08","77.91","","273.64","94.28","1367.51","138","401.13","703.08","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.14","59.3","","720.78","230.14","2010.94","427","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","535.14","59.3","","344.45","344.45","344.45","1 through 10","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","707.96","78.45","","1120.13","1120.13","1120.13","1 through 10","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","707.96","78.45","","456.17","105.33","1284.66","242","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","AETNA [1001]","HB CH AETNA HMO / PPO","646.48","58.3","","464.71","67.87","1012.10","221","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","646.48","58.3","","293.04","293.04","293.04","11","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","587.71","53","","983.89","983.89","983.89","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","643.16","58","","677.18","677.18","677.18","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","693.06","62.5","","46.58","46.58","46.58","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","809.49","73","","747.15","747.15","747.15","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.90","44.45","","1141.67","481.21","1141.67","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.90","44.45","","76.54","76.54","76.54","1 through 10","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.89","831.67","WELLPOINT [1015]","HB CH WELLPOINT","863.94","77.91","","273.64","94.28","1367.51","138","492.9","863.94","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.89","831.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","657.57","59.3","","720.78","230.14","2010.94","427","554.45","869.92","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.89","831.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","657.57","59.3","","344.45","344.45","344.45","1 through 10","554.45","869.92","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.89","831.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","869.92","78.45","","1120.13","1120.13","1120.13","1 through 10","554.45","869.92","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.89","831.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","869.92","78.45","","456.17","105.33","1284.66","242","554.45","869.92","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","AETNA [1001]","HB CH AETNA HMO / PPO","351.29","58.3","","464.71","67.87","1012.10","221","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","351.29","58.3","","293.04","293.04","293.04","11","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","319.35","53","","983.89","983.89","983.89","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","349.48","58","","677.18","677.18","677.18","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","376.59","62.5","","46.58","46.58","46.58","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","439.86","73","","747.15","747.15","747.15","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.83","44.45","","1141.67","481.21","1141.67","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.83","44.45","","76.54","76.54","76.54","1 through 10","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","WELLPOINT [1015]","HB CH WELLPOINT","469.45","77.91","","273.64","94.28","1367.51","138","267.83","469.45","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","357.31","59.3","","720.78","230.14","2010.94","427","301.28","472.7","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","357.31","59.3","","344.45","344.45","344.45","1 through 10","301.28","472.7","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","472.70","78.45","","1120.13","1120.13","1120.13","1 through 10","301.28","472.7","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","472.70","78.45","","456.17","105.33","1284.66","242","301.28","472.7","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","AETNA [1001]","HB CH AETNA HMO / PPO","919.47","58.3","","464.71","67.87","1012.10","221","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","919.47","58.3","","293.04","293.04","293.04","11","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","835.88","53","","983.89","983.89","983.89","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","914.74","58","","677.18","677.18","677.18","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","985.71","62.5","","46.58","46.58","46.58","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1151.30","73","","747.15","747.15","747.15","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.03","44.45","","1141.67","481.21","1141.67","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.03","44.45","","76.54","76.54","76.54","1 through 10","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","WELLPOINT [1015]","HB CH WELLPOINT","1228.74","77.91","","273.64","94.28","1367.51","138","701.03","1228.74","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","935.24","59.3","","720.78","230.14","2010.94","427","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","935.24","59.3","","344.45","344.45","344.45","1 through 10","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1237.26","78.45","","1120.13","1120.13","1120.13","1 through 10","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1237.26","78.45","","456.17","105.33","1284.66","242","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","AETNA [1001]","HB CH AETNA HMO / PPO","381.91","58.3","","464.71","67.87","1012.10","221","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","381.91","58.3","","293.04","293.04","293.04","11","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","347.19","53","","983.89","983.89","983.89","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","379.95","58","","677.18","677.18","677.18","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","409.43","62.5","","46.58","46.58","46.58","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","478.21","73","","747.15","747.15","747.15","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","291.18","44.45","","1141.67","481.21","1141.67","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","291.18","44.45","","76.54","76.54","76.54","1 through 10","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","WELLPOINT [1015]","HB CH WELLPOINT","510.37","77.91","","273.64","94.28","1367.51","138","291.18","510.37","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","388.46","59.3","","720.78","230.14","2010.94","427","327.54","513.91","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","388.46","59.3","","344.45","344.45","344.45","1 through 10","327.54","513.91","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","513.91","78.45","","1120.13","1120.13","1120.13","1 through 10","327.54","513.91","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","513.91","78.45","","456.17","105.33","1284.66","242","327.54","513.91","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","AETNA [1001]","HB CH AETNA HMO / PPO","428.75","58.3","","464.71","67.87","1012.10","221","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","428.75","58.3","","293.04","293.04","293.04","11","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","389.77","53","","983.89","983.89","983.89","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.54","58","","677.18","677.18","677.18","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","459.64","62.5","","46.58","46.58","46.58","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","536.86","73","","747.15","747.15","747.15","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.89","44.45","","1141.67","481.21","1141.67","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.89","44.45","","76.54","76.54","76.54","1 through 10","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","WELLPOINT [1015]","HB CH WELLPOINT","572.97","77.91","","273.64","94.28","1367.51","138","326.89","572.97","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","436.10","59.3","","720.78","230.14","2010.94","427","367.71","576.94","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","436.10","59.3","","344.45","344.45","344.45","1 through 10","367.71","576.94","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","576.94","78.45","","1120.13","1120.13","1120.13","1 through 10","367.71","576.94","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.94","78.45","","456.17","105.33","1284.66","242","367.71","576.94","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","AETNA [1001]","HB CH AETNA HMO / PPO","457.57","58.3","","464.71","67.87","1012.10","221","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","457.57","58.3","","293.04","293.04","293.04","11","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","415.98","53","","983.89","983.89","983.89","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","455.22","58","","677.18","677.18","677.18","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","490.54","62.5","","46.58","46.58","46.58","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","572.95","73","","747.15","747.15","747.15","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.87","44.45","","1141.67","481.21","1141.67","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.87","44.45","","76.54","76.54","76.54","1 through 10","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","WELLPOINT [1015]","HB CH WELLPOINT","611.48","77.91","","273.64","94.28","1367.51","138","348.87","611.48","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","465.42","59.3","","720.78","230.14","2010.94","427","392.43","615.72","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","465.42","59.3","","344.45","344.45","344.45","1 through 10","392.43","615.72","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","615.72","78.45","","1120.13","1120.13","1120.13","1 through 10","392.43","615.72","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","615.72","78.45","","456.17","105.33","1284.66","242","392.43","615.72","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","AETNA [1001]","HB CH AETNA HMO / PPO","1210.31","58.3","","464.71","67.87","1012.10","221","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1210.31","58.3","","293.04","293.04","293.04","11","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1100.28","53","","983.89","983.89","983.89","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1204.08","58","","677.18","677.18","677.18","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1297.50","62.5","","46.58","46.58","46.58","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1515.48","73","","747.15","747.15","747.15","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","922.78","44.45","","1141.67","481.21","1141.67","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","922.78","44.45","","76.54","76.54","76.54","1 through 10","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.00","1557.00","WELLPOINT [1015]","HB CH WELLPOINT","1617.41","77.91","","273.64","94.28","1367.51","138","922.78","1617.41","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.00","1557.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1231.07","59.3","","720.78","230.14","2010.94","427","1038","1628.62","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.00","1557.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1231.07","59.3","","344.45","344.45","344.45","1 through 10","1038","1628.62","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.00","1557.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1628.62","78.45","","1120.13","1120.13","1120.13","1 through 10","1038","1628.62","percent of total billed charges",""
"BONE PLATE 2.0/2.3 1.3MM TRILOCK 6 HOLE","SUP-ITM-10274558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.00","1557.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1628.62","78.45","","456.17","105.33","1284.66","242","1038","1628.62","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","AETNA [1001]","HB CH AETNA HMO / PPO","885.27","58.3","","464.71","67.87","1012.10","221","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","885.27","58.3","","293.04","293.04","293.04","11","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.79","53","","983.89","983.89","983.89","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","880.72","58","","677.18","677.18","677.18","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","949.05","62.5","","46.58","46.58","46.58","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1108.49","73","","747.15","747.15","747.15","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.96","44.45","","1141.67","481.21","1141.67","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.96","44.45","","76.54","76.54","76.54","1 through 10","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.48","1138.86","WELLPOINT [1015]","HB CH WELLPOINT","1183.05","77.91","","273.64","94.28","1367.51","138","674.96","1183.05","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.48","1138.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","900.46","59.3","","720.78","230.14","2010.94","427","759.24","1191.25","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.48","1138.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","900.46","59.3","","344.45","344.45","344.45","1 through 10","759.24","1191.25","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.48","1138.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1191.25","78.45","","1120.13","1120.13","1120.13","1 through 10","759.24","1191.25","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.48","1138.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1191.25","78.45","","456.17","105.33","1284.66","242","759.24","1191.25","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","AETNA [1001]","HB CH AETNA HMO / PPO","955.81","58.3","","464.71","67.87","1012.10","221","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","955.81","58.3","","293.04","293.04","293.04","11","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","868.92","53","","983.89","983.89","983.89","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","950.89","58","","677.18","677.18","677.18","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1024.67","62.5","","46.58","46.58","46.58","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1196.81","73","","747.15","747.15","747.15","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.74","44.45","","1141.67","481.21","1141.67","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.74","44.45","","76.54","76.54","76.54","1 through 10","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.47","1229.60","WELLPOINT [1015]","HB CH WELLPOINT","1277.31","77.91","","273.64","94.28","1367.51","138","728.74","1277.31","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.47","1229.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","972.21","59.3","","720.78","230.14","2010.94","427","819.74","1286.16","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.47","1229.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","972.21","59.3","","344.45","344.45","344.45","1 through 10","819.74","1286.16","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.47","1229.60","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1286.16","78.45","","1120.13","1120.13","1120.13","1 through 10","819.74","1286.16","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.47","1229.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1286.16","78.45","","456.17","105.33","1284.66","242","819.74","1286.16","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","AETNA [1001]","HB CH AETNA HMO / PPO","658.13","58.3","","464.71","67.87","1012.10","221","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","658.13","58.3","","293.04","293.04","293.04","11","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","598.30","53","","983.89","983.89","983.89","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","654.74","58","","677.18","677.18","677.18","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","705.54","62.5","","46.58","46.58","46.58","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","824.08","73","","747.15","747.15","747.15","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","501.78","44.45","","1141.67","481.21","1141.67","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","501.78","44.45","","76.54","76.54","76.54","1 through 10","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1128.87","846.65","WELLPOINT [1015]","HB CH WELLPOINT","879.50","77.91","","273.64","94.28","1367.51","138","501.78","879.5","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1128.87","846.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","669.42","59.3","","720.78","230.14","2010.94","427","564.44","885.6","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1128.87","846.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","669.42","59.3","","344.45","344.45","344.45","1 through 10","564.44","885.6","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1128.87","846.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","885.60","78.45","","1120.13","1120.13","1120.13","1 through 10","564.44","885.6","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1128.87","846.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","885.60","78.45","","456.17","105.33","1284.66","242","564.44","885.6","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","AETNA [1001]","HB CH AETNA HMO / PPO","858.74","58.3","","464.71","67.87","1012.10","221","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","858.74","58.3","","293.04","293.04","293.04","11","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","780.67","53","","983.89","983.89","983.89","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","854.32","58","","677.18","677.18","677.18","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","920.61","62.5","","46.58","46.58","46.58","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1075.27","73","","747.15","747.15","747.15","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.74","44.45","","1141.67","481.21","1141.67","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.74","44.45","","76.54","76.54","76.54","1 through 10","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","WELLPOINT [1015]","HB CH WELLPOINT","1147.59","77.91","","273.64","94.28","1367.51","138","654.74","1147.59","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","873.47","59.3","","720.78","230.14","2010.94","427","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","873.47","59.3","","344.45","344.45","344.45","1 through 10","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1155.54","78.45","","1120.13","1120.13","1120.13","1 through 10","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1155.54","78.45","","456.17","105.33","1284.66","242","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","AETNA [1001]","HB CH AETNA HMO / PPO","927.98","58.3","","464.71","67.87","1012.10","221","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","927.98","58.3","","293.04","293.04","293.04","11","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","843.62","53","","983.89","983.89","983.89","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","923.21","58","","677.18","677.18","677.18","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","994.84","62.5","","46.58","46.58","46.58","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1161.97","73","","747.15","747.15","747.15","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","707.53","44.45","","1141.67","481.21","1141.67","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","707.53","44.45","","76.54","76.54","76.54","1 through 10","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","WELLPOINT [1015]","HB CH WELLPOINT","1240.12","77.91","","273.64","94.28","1367.51","138","707.53","1240.12","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","943.90","59.3","","720.78","230.14","2010.94","427","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","943.90","59.3","","344.45","344.45","344.45","1 through 10","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1248.72","78.45","","1120.13","1120.13","1120.13","1 through 10","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1248.72","78.45","","456.17","105.33","1284.66","242","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","AETNA [1001]","HB CH AETNA HMO / PPO","915.69","58.3","","464.71","67.87","1012.10","221","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","915.69","58.3","","293.04","293.04","293.04","11","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","832.44","53","","983.89","983.89","983.89","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","910.98","58","","677.18","677.18","677.18","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","981.66","62.5","","46.58","46.58","46.58","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1146.57","73","","747.15","747.15","747.15","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","698.15","44.45","","1141.67","481.21","1141.67","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","698.15","44.45","","76.54","76.54","76.54","1 through 10","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.65","1177.99","WELLPOINT [1015]","HB CH WELLPOINT","1223.69","77.91","","273.64","94.28","1367.51","138","698.15","1223.69","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.65","1177.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","931.40","59.3","","720.78","230.14","2010.94","427","785.33","1232.17","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.65","1177.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","931.40","59.3","","344.45","344.45","344.45","1 through 10","785.33","1232.17","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.65","1177.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1232.17","78.45","","1120.13","1120.13","1120.13","1 through 10","785.33","1232.17","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.65","1177.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1232.17","78.45","","456.17","105.33","1284.66","242","785.33","1232.17","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","AETNA [1001]","HB CH AETNA HMO / PPO","1002.51","58.3","","464.71","67.87","1012.10","221","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1002.51","58.3","","293.04","293.04","293.04","11","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","911.37","53","","983.89","983.89","983.89","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","997.35","58","","677.18","677.18","677.18","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1074.73","62.5","","46.58","46.58","46.58","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1255.29","73","","747.15","747.15","747.15","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","764.35","44.45","","1141.67","481.21","1141.67","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","764.35","44.45","","76.54","76.54","76.54","1 through 10","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","WELLPOINT [1015]","HB CH WELLPOINT","1339.72","77.91","","273.64","94.28","1367.51","138","764.35","1339.72","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1019.71","59.3","","720.78","230.14","2010.94","427","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1019.71","59.3","","344.45","344.45","344.45","1 through 10","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1349.00","78.45","","1120.13","1120.13","1120.13","1 through 10","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1349.00","78.45","","456.17","105.33","1284.66","242","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","AETNA [1001]","HB CH AETNA HMO / PPO","988.81","58.3","","464.71","67.87","1012.10","221","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","988.81","58.3","","293.04","293.04","293.04","11","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","898.92","53","","983.89","983.89","983.89","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","983.73","58","","677.18","677.18","677.18","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1060.05","62.5","","46.58","46.58","46.58","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1238.14","73","","747.15","747.15","747.15","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.91","44.45","","1141.67","481.21","1141.67","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.91","44.45","","76.54","76.54","76.54","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","WELLPOINT [1015]","HB CH WELLPOINT","1321.42","77.91","","273.64","94.28","1367.51","138","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.78","59.3","","720.78","230.14","2010.94","427","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1005.78","59.3","","344.45","344.45","344.45","1 through 10","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1330.57","78.45","","1120.13","1120.13","1120.13","1 through 10","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1330.57","78.45","","456.17","105.33","1284.66","242","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","AETNA [1001]","HB CH AETNA HMO / PPO","816.03","58.3","","464.71","67.87","1012.10","221","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.03","58.3","","293.04","293.04","293.04","11","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","741.85","53","","983.89","983.89","983.89","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","811.83","58","","677.18","677.18","677.18","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","874.82","62.5","","46.58","46.58","46.58","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1021.79","73","","747.15","747.15","747.15","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.17","44.45","","1141.67","481.21","1141.67","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.17","44.45","","76.54","76.54","76.54","1 through 10","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","WELLPOINT [1015]","HB CH WELLPOINT","1090.51","77.91","","273.64","94.28","1367.51","138","622.17","1090.51","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.03","59.3","","720.78","230.14","2010.94","427","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","830.03","59.3","","344.45","344.45","344.45","1 through 10","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1098.07","78.45","","1120.13","1120.13","1120.13","1 through 10","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1098.07","78.45","","456.17","105.33","1284.66","242","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","AETNA [1001]","HB CH AETNA HMO / PPO","903.39","58.3","","464.71","67.87","1012.10","221","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","903.39","58.3","","293.04","293.04","293.04","11","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","821.27","53","","983.89","983.89","983.89","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","898.74","58","","677.18","677.18","677.18","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","968.48","62.5","","46.58","46.58","46.58","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1131.18","73","","747.15","747.15","747.15","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","688.78","44.45","","1141.67","481.21","1141.67","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","688.78","44.45","","76.54","76.54","76.54","1 through 10","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","WELLPOINT [1015]","HB CH WELLPOINT","1207.26","77.91","","273.64","94.28","1367.51","138","688.78","1207.26","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","918.89","59.3","","720.78","230.14","2010.94","427","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","918.89","59.3","","344.45","344.45","344.45","1 through 10","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1215.63","78.45","","1120.13","1120.13","1120.13","1 through 10","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1215.63","78.45","","456.17","105.33","1284.66","242","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","AETNA [1001]","HB CH AETNA HMO / PPO","1340.21","58.3","","464.71","67.87","1012.10","221","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1340.21","58.3","","293.04","293.04","293.04","11","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.37","53","","983.89","983.89","983.89","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1333.31","58","","677.18","677.18","677.18","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1436.76","62.5","","46.58","46.58","46.58","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1678.13","73","","747.15","747.15","747.15","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.82","44.45","","1141.67","481.21","1141.67","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.82","44.45","","76.54","76.54","76.54","1 through 10","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2298.81","1724.11","WELLPOINT [1015]","HB CH WELLPOINT","1791.00","77.91","","273.64","94.28","1367.51","138","1021.82","1791","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2298.81","1724.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.19","59.3","","720.78","230.14","2010.94","427","1149.41","1803.42","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2298.81","1724.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1363.19","59.3","","344.45","344.45","344.45","1 through 10","1149.41","1803.42","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2298.81","1724.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1803.42","78.45","","1120.13","1120.13","1120.13","1 through 10","1149.41","1803.42","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2298.81","1724.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.42","78.45","","456.17","105.33","1284.66","242","1149.41","1803.42","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","AETNA [1001]","HB CH AETNA HMO / PPO","577.24","58.3","","464.71","67.87","1012.10","221","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","577.24","58.3","","293.04","293.04","293.04","11","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","524.76","53","","983.89","983.89","983.89","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","574.27","58","","677.18","677.18","677.18","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","618.83","62.5","","46.58","46.58","46.58","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","722.79","73","","747.15","747.15","747.15","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.11","44.45","","1141.67","481.21","1141.67","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.11","44.45","","76.54","76.54","76.54","1 through 10","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","WELLPOINT [1015]","HB CH WELLPOINT","771.40","77.91","","273.64","94.28","1367.51","138","440.11","771.4","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","587.14","59.3","","720.78","230.14","2010.94","427","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","587.14","59.3","","344.45","344.45","344.45","1 through 10","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","776.75","78.45","","1120.13","1120.13","1120.13","1 through 10","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","776.75","78.45","","456.17","105.33","1284.66","242","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","AETNA [1001]","HB CH AETNA HMO / PPO","629.01","58.3","","464.71","67.87","1012.10","221","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","629.01","58.3","","293.04","293.04","293.04","11","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","571.83","53","","983.89","983.89","983.89","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","625.77","58","","677.18","677.18","677.18","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","674.33","62.5","","46.58","46.58","46.58","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","787.61","73","","747.15","747.15","747.15","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.58","44.45","","1141.67","481.21","1141.67","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.58","44.45","","76.54","76.54","76.54","1 through 10","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.92","809.19","WELLPOINT [1015]","HB CH WELLPOINT","840.59","77.91","","273.64","94.28","1367.51","138","479.58","840.59","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.92","809.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","639.80","59.3","","720.78","230.14","2010.94","427","539.46","846.41","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.92","809.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","639.80","59.3","","344.45","344.45","344.45","1 through 10","539.46","846.41","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.92","809.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","846.41","78.45","","1120.13","1120.13","1120.13","1 through 10","539.46","846.41","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.92","809.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","846.41","78.45","","456.17","105.33","1284.66","242","539.46","846.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","AETNA [1001]","HB CH AETNA HMO / PPO","1054.44","58.3","","464.71","67.87","1012.10","221","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1054.44","58.3","","293.04","293.04","293.04","11","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.58","53","","983.89","983.89","983.89","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1049.01","58","","677.18","677.18","677.18","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1130.40","62.5","","46.58","46.58","46.58","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1320.31","73","","747.15","747.15","747.15","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.94","44.45","","1141.67","481.21","1141.67","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.94","44.45","","76.54","76.54","76.54","1 through 10","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","WELLPOINT [1015]","HB CH WELLPOINT","1409.11","77.91","","273.64","94.28","1367.51","138","803.94","1409.11","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1072.52","59.3","","720.78","230.14","2010.94","427","904.32","1418.88","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1072.52","59.3","","344.45","344.45","344.45","1 through 10","904.32","1418.88","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1418.88","78.45","","1120.13","1120.13","1120.13","1 through 10","904.32","1418.88","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.88","78.45","","456.17","105.33","1284.66","242","904.32","1418.88","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","AETNA [1001]","HB CH AETNA HMO / PPO","573.36","58.3","","464.71","67.87","1012.10","221","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","573.36","58.3","","293.04","293.04","293.04","11","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","521.23","53","","983.89","983.89","983.89","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","570.41","58","","677.18","677.18","677.18","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","614.66","62.5","","46.58","46.58","46.58","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","717.93","73","","747.15","747.15","747.15","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.15","44.45","","1141.67","481.21","1141.67","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.15","44.45","","76.54","76.54","76.54","1 through 10","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","WELLPOINT [1015]","HB CH WELLPOINT","766.21","77.91","","273.64","94.28","1367.51","138","437.15","766.21","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","583.19","59.3","","720.78","230.14","2010.94","427","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","583.19","59.3","","344.45","344.45","344.45","1 through 10","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","771.52","78.45","","1120.13","1120.13","1120.13","1 through 10","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","771.52","78.45","","456.17","105.33","1284.66","242","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","AETNA [1001]","HB CH AETNA HMO / PPO","498.29","58.3","","464.71","67.87","1012.10","221","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.29","58.3","","293.04","293.04","293.04","11","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","452.99","53","","983.89","983.89","983.89","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.73","58","","677.18","677.18","677.18","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","534.19","62.5","","46.58","46.58","46.58","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","623.93","73","","747.15","747.15","747.15","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.91","44.45","","1141.67","481.21","1141.67","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.91","44.45","","76.54","76.54","76.54","1 through 10","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","WELLPOINT [1015]","HB CH WELLPOINT","665.90","77.91","","273.64","94.28","1367.51","138","379.91","665.9","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","506.84","59.3","","720.78","230.14","2010.94","427","427.35","670.51","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","506.84","59.3","","344.45","344.45","344.45","1 through 10","427.35","670.51","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","670.51","78.45","","1120.13","1120.13","1120.13","1 through 10","427.35","670.51","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.51","78.45","","456.17","105.33","1284.66","242","427.35","670.51","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","AETNA [1001]","HB CH AETNA HMO / PPO","2628.96","58.3","","464.71","67.87","1012.10","221","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2628.96","58.3","","293.04","293.04","293.04","11","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2389.96","53","","983.89","983.89","983.89","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2615.43","58","","677.18","677.18","677.18","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2818.35","62.5","","46.58","46.58","46.58","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3291.83","73","","747.15","747.15","747.15","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2004.41","44.45","","1141.67","481.21","1141.67","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2004.41","44.45","","76.54","76.54","76.54","1 through 10","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","both","","","4509.36","3382.02","WELLPOINT [1015]","HB CH WELLPOINT","3513.24","77.91","","273.64","94.28","1367.51","138","2004.41","3513.24","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4509.36","3382.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","2674.05","59.3","","720.78","230.14","2010.94","427","2254.68","3537.59","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4509.36","3382.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2674.05","59.3","","344.45","344.45","344.45","1 through 10","2254.68","3537.59","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4509.36","3382.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3537.59","78.45","","1120.13","1120.13","1120.13","1 through 10","2254.68","3537.59","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 122 7 HOLE CLAVICLE VARIAX TITANIUM LOCKING SUPERIOR LATERAL RIGHT","SUP-ITM-10144687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4509.36","3382.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3537.59","78.45","","456.17","105.33","1284.66","242","2254.68","3537.59","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","AETNA [1001]","HB CH AETNA HMO / PPO","174.15","58.3","","464.71","67.87","1012.10","221","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.15","58.3","","293.04","293.04","293.04","11","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","158.32","53","","983.89","983.89","983.89","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","173.25","58","","677.18","677.18","677.18","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","186.69","62.5","","46.58","46.58","46.58","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","218.06","73","","747.15","747.15","747.15","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","44.45","","1141.67","481.21","1141.67","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","44.45","","76.54","76.54","76.54","1 through 10","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","both","","","298.71","224.03","WELLPOINT [1015]","HB CH WELLPOINT","232.72","77.91","","273.64","94.28","1367.51","138","132.78","232.72","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","298.71","224.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.14","59.3","","720.78","230.14","2010.94","427","149.36","234.34","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","298.71","224.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.14","59.3","","344.45","344.45","344.45","1 through 10","149.36","234.34","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","298.71","224.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","234.34","78.45","","1120.13","1120.13","1120.13","1 through 10","149.36","234.34","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 4.00 77 UNIVERSAL 6 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10041332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","298.71","224.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","234.34","78.45","","456.17","105.33","1284.66","242","149.36","234.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","AETNA [1001]","HB CH AETNA HMO / PPO","190.26","58.3","","464.71","67.87","1012.10","221","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","190.26","58.3","","293.04","293.04","293.04","11","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","172.96","53","","983.89","983.89","983.89","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","189.28","58","","677.18","677.18","677.18","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","203.96","62.5","","46.58","46.58","46.58","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","747.15","747.15","747.15","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","1141.67","481.21","1141.67","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","76.54","76.54","76.54","1 through 10","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","WELLPOINT [1015]","HB CH WELLPOINT","254.25","77.91","","273.64","94.28","1367.51","138","145.06","254.25","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.52","59.3","","720.78","230.14","2010.94","427","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","193.52","59.3","","344.45","344.45","344.45","1 through 10","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","1120.13","1120.13","1120.13","1 through 10","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","456.17","105.33","1284.66","242","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","AETNA [1001]","HB CH AETNA HMO / PPO","192.86","58.3","","464.71","67.87","1012.10","221","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.86","58.3","","293.04","293.04","293.04","11","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","175.33","53","","983.89","983.89","983.89","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","191.87","58","","677.18","677.18","677.18","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","206.76","62.5","","46.58","46.58","46.58","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","241.49","73","","747.15","747.15","747.15","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.05","44.45","","1141.67","481.21","1141.67","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.05","44.45","","76.54","76.54","76.54","1 through 10","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.81","248.11","WELLPOINT [1015]","HB CH WELLPOINT","257.73","77.91","","273.64","94.28","1367.51","138","147.05","257.73","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.81","248.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","196.17","59.3","","720.78","230.14","2010.94","427","165.41","259.52","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.81","248.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","196.17","59.3","","344.45","344.45","344.45","1 through 10","165.41","259.52","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.81","248.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","259.52","78.45","","1120.13","1120.13","1120.13","1 through 10","165.41","259.52","percent of total billed charges",""
"BONE PLATE 2.7X3.5 4.0MM 90 UNIVERSAL 7 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10042508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.81","248.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","259.52","78.45","","456.17","105.33","1284.66","242","165.41","259.52","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","AETNA [1001]","HB CH AETNA HMO / PPO","215.34","58.3","","464.71","67.87","1012.10","221","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","215.34","58.3","","293.04","293.04","293.04","11","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","195.76","53","","983.89","983.89","983.89","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","214.23","58","","677.18","677.18","677.18","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","230.85","62.5","","46.58","46.58","46.58","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","269.63","73","","747.15","747.15","747.15","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.18","44.45","","1141.67","481.21","1141.67","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.18","44.45","","76.54","76.54","76.54","1 through 10","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.36","277.02","WELLPOINT [1015]","HB CH WELLPOINT","287.77","77.91","","273.64","94.28","1367.51","138","164.18","287.77","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.36","277.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","219.03","59.3","","720.78","230.14","2010.94","427","184.68","289.76","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.36","277.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","219.03","59.3","","344.45","344.45","344.45","1 through 10","184.68","289.76","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.36","277.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","289.76","78.45","","1120.13","1120.13","1120.13","1 through 10","184.68","289.76","percent of total billed charges",""
"BONE PLATE 2.7X3.5MM 103 UNIVERSAL 8 HOLE SS 1/3 TUBULAR COLLARED","SUP-ITM-10045380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.36","277.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","289.76","78.45","","456.17","105.33","1284.66","242","184.68","289.76","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","AETNA [1001]","HB CH AETNA HMO / PPO","218.73","58.3","","464.71","67.87","1012.10","221","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.73","58.3","","293.04","293.04","293.04","11","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.85","53","","983.89","983.89","983.89","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","217.60","58","","677.18","677.18","677.18","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","234.49","62.5","","46.58","46.58","46.58","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.88","73","","747.15","747.15","747.15","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.77","44.45","","1141.67","481.21","1141.67","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.77","44.45","","76.54","76.54","76.54","1 through 10","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","WELLPOINT [1015]","HB CH WELLPOINT","292.30","77.91","","273.64","94.28","1367.51","138","166.77","292.3","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.48","59.3","","720.78","230.14","2010.94","427","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","222.48","59.3","","344.45","344.45","344.45","1 through 10","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","294.33","78.45","","1120.13","1120.13","1120.13","1 through 10","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.33","78.45","","456.17","105.33","1284.66","242","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","AETNA [1001]","HB CH AETNA HMO / PPO","96.33","58.3","","464.71","67.87","1012.10","221","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","96.33","58.3","","293.04","293.04","293.04","11","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","87.58","53","","983.89","983.89","983.89","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","95.84","58","","677.18","677.18","677.18","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","103.28","62.5","","46.58","46.58","46.58","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","120.63","73","","747.15","747.15","747.15","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.45","44.45","","1141.67","481.21","1141.67","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.45","44.45","","76.54","76.54","76.54","1 through 10","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","165.24","123.93","WELLPOINT [1015]","HB CH WELLPOINT","128.74","77.91","","273.64","94.28","1367.51","138","73.45","128.74","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","165.24","123.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.99","59.3","","720.78","230.14","2010.94","427","82.62","129.63","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","165.24","123.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","97.99","59.3","","344.45","344.45","344.45","1 through 10","82.62","129.63","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","165.24","123.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","129.63","78.45","","1120.13","1120.13","1120.13","1 through 10","82.62","129.63","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","165.24","123.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.63","78.45","","456.17","105.33","1284.66","242","82.62","129.63","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","AETNA [1001]","HB CH AETNA HMO / PPO","107.04","58.3","","464.71","67.87","1012.10","221","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","107.04","58.3","","293.04","293.04","293.04","11","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.31","53","","983.89","983.89","983.89","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","106.49","58","","677.18","677.18","677.18","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","114.75","62.5","","46.58","46.58","46.58","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","134.03","73","","747.15","747.15","747.15","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.61","44.45","","1141.67","481.21","1141.67","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.61","44.45","","76.54","76.54","76.54","1 through 10","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","WELLPOINT [1015]","HB CH WELLPOINT","143.04","77.91","","273.64","94.28","1367.51","138","81.61","143.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.87","59.3","","720.78","230.14","2010.94","427","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","108.87","59.3","","344.45","344.45","344.45","1 through 10","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","144.03","78.45","","1120.13","1120.13","1120.13","1 through 10","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","144.03","78.45","","456.17","105.33","1284.66","242","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","AETNA [1001]","HB CH AETNA HMO / PPO","212.26","58.3","","464.71","67.87","1012.10","221","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","212.26","58.3","","293.04","293.04","293.04","11","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","192.96","53","","983.89","983.89","983.89","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","211.17","58","","677.18","677.18","677.18","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","227.55","62.5","","46.58","46.58","46.58","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","265.78","73","","747.15","747.15","747.15","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.83","44.45","","1141.67","481.21","1141.67","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.83","44.45","","76.54","76.54","76.54","1 through 10","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","WELLPOINT [1015]","HB CH WELLPOINT","283.65","77.91","","273.64","94.28","1367.51","138","161.83","283.65","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","215.90","59.3","","720.78","230.14","2010.94","427","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","215.90","59.3","","344.45","344.45","344.45","1 through 10","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","285.62","78.45","","1120.13","1120.13","1120.13","1 through 10","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","285.62","78.45","","456.17","105.33","1284.66","242","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","AETNA [1001]","HB CH AETNA HMO / PPO","229.08","58.3","","464.71","67.87","1012.10","221","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","229.08","58.3","","293.04","293.04","293.04","11","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","208.26","53","","983.89","983.89","983.89","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","227.91","58","","677.18","677.18","677.18","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","245.59","62.5","","46.58","46.58","46.58","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.85","73","","747.15","747.15","747.15","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.66","44.45","","1141.67","481.21","1141.67","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.66","44.45","","76.54","76.54","76.54","1 through 10","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","WELLPOINT [1015]","HB CH WELLPOINT","306.14","77.91","","273.64","94.28","1367.51","138","174.66","306.14","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","233.01","59.3","","720.78","230.14","2010.94","427","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","233.01","59.3","","344.45","344.45","344.45","1 through 10","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","308.26","78.45","","1120.13","1120.13","1120.13","1 through 10","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","308.26","78.45","","456.17","105.33","1284.66","242","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","AETNA [1001]","HB CH AETNA HMO / PPO","805.03","58.3","","464.71","67.87","1012.10","221","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","805.03","58.3","","293.04","293.04","293.04","11","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","731.85","53","","983.89","983.89","983.89","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","800.89","58","","677.18","677.18","677.18","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","863.03","62.5","","46.58","46.58","46.58","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1008.01","73","","747.15","747.15","747.15","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.78","44.45","","1141.67","481.21","1141.67","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.78","44.45","","76.54","76.54","76.54","1 through 10","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","WELLPOINT [1015]","HB CH WELLPOINT","1075.81","77.91","","273.64","94.28","1367.51","138","613.78","1075.81","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","818.84","59.3","","720.78","230.14","2010.94","427","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","818.84","59.3","","344.45","344.45","344.45","1 through 10","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1083.27","78.45","","1120.13","1120.13","1120.13","1 through 10","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1083.27","78.45","","456.17","105.33","1284.66","242","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","AETNA [1001]","HB CH AETNA HMO / PPO","519.65","58.3","","464.71","67.87","1012.10","221","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","519.65","58.3","","293.04","293.04","293.04","11","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","472.40","53","","983.89","983.89","983.89","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","516.97","58","","677.18","677.18","677.18","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","557.08","62.5","","46.58","46.58","46.58","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","650.67","73","","747.15","747.15","747.15","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.20","44.45","","1141.67","481.21","1141.67","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.20","44.45","","76.54","76.54","76.54","1 through 10","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","WELLPOINT [1015]","HB CH WELLPOINT","694.44","77.91","","273.64","94.28","1367.51","138","396.2","694.44","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","528.56","59.3","","720.78","230.14","2010.94","427","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","528.56","59.3","","344.45","344.45","344.45","1 through 10","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","699.25","78.45","","1120.13","1120.13","1120.13","1 through 10","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","699.25","78.45","","456.17","105.33","1284.66","242","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","AETNA [1001]","HB CH AETNA HMO / PPO","1425.44","58.3","","464.71","67.87","1012.10","221","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1425.44","58.3","","293.04","293.04","293.04","11","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1295.85","53","","983.89","983.89","983.89","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1418.10","58","","677.18","677.18","677.18","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1528.13","62.5","","46.58","46.58","46.58","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1784.85","73","","747.15","747.15","747.15","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.80","44.45","","1141.67","481.21","1141.67","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.80","44.45","","76.54","76.54","76.54","1 through 10","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2445.00","1833.75","WELLPOINT [1015]","HB CH WELLPOINT","1904.90","77.91","","273.64","94.28","1367.51","138","1086.8","1904.9","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2445.00","1833.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1449.89","59.3","","720.78","230.14","2010.94","427","1222.5","1918.1","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2445.00","1833.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1449.89","59.3","","344.45","344.45","344.45","1 through 10","1222.5","1918.1","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2445.00","1833.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1918.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1222.5","1918.1","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2445.00","1833.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1918.10","78.45","","456.17","105.33","1284.66","242","1222.5","1918.1","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","AETNA [1001]","HB CH AETNA HMO / PPO","3831.09","58.3","","464.71","67.87","1012.10","221","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3831.09","58.3","","293.04","293.04","293.04","11","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3482.81","53","","983.89","983.89","983.89","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3811.38","58","","677.18","677.18","677.18","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4107.09","62.5","","46.58","46.58","46.58","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4797.08","73","","747.15","747.15","747.15","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2920.96","44.45","","1141.67","481.21","1141.67","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2920.96","44.45","","76.54","76.54","76.54","1 through 10","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","both","","","6571.34","4928.50","WELLPOINT [1015]","HB CH WELLPOINT","5119.73","77.91","","273.64","94.28","1367.51","138","2920.96","5119.73","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6571.34","4928.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3896.80","59.3","","720.78","230.14","2010.94","427","3285.67","5155.22","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6571.34","4928.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3896.80","59.3","","344.45","344.45","344.45","1 through 10","3285.67","5155.22","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6571.34","4928.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5155.22","78.45","","1120.13","1120.13","1120.13","1 through 10","3285.67","5155.22","percent of total billed charges",""
"BONE PLATE 202MM TITANIUM DISTAL LATERAL FEMORAL RIGHT","SUP-ITM-10144634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6571.34","4928.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5155.22","78.45","","456.17","105.33","1284.66","242","3285.67","5155.22","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","AETNA [1001]","HB CH AETNA HMO / PPO","198.67","58.3","","464.71","67.87","1012.10","221","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.67","58.3","","293.04","293.04","293.04","11","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.61","53","","983.89","983.89","983.89","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","197.65","58","","677.18","677.18","677.18","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","212.98","62.5","","46.58","46.58","46.58","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.76","73","","747.15","747.15","747.15","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.47","44.45","","1141.67","481.21","1141.67","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.47","44.45","","76.54","76.54","76.54","1 through 10","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","WELLPOINT [1015]","HB CH WELLPOINT","265.49","77.91","","273.64","94.28","1367.51","138","151.47","265.49","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.08","59.3","","720.78","230.14","2010.94","427","170.39","267.33","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","202.08","59.3","","344.45","344.45","344.45","1 through 10","170.39","267.33","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","267.33","78.45","","1120.13","1120.13","1120.13","1 through 10","170.39","267.33","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.33","78.45","","456.17","105.33","1284.66","242","170.39","267.33","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","AETNA [1001]","HB CH AETNA HMO / PPO","997.23","58.3","","464.71","67.87","1012.10","221","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","997.23","58.3","","293.04","293.04","293.04","11","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","906.57","53","","983.89","983.89","983.89","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","992.10","58","","677.18","677.18","677.18","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1069.07","62.5","","46.58","46.58","46.58","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1248.67","73","","747.15","747.15","747.15","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","760.32","44.45","","1141.67","481.21","1141.67","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","760.32","44.45","","76.54","76.54","76.54","1 through 10","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","WELLPOINT [1015]","HB CH WELLPOINT","1332.66","77.91","","273.64","94.28","1367.51","138","760.32","1332.66","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","1014.33","59.3","","720.78","230.14","2010.94","427","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1014.33","59.3","","344.45","344.45","344.45","1 through 10","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1341.90","78.45","","1120.13","1120.13","1120.13","1 through 10","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1341.90","78.45","","456.17","105.33","1284.66","242","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","AETNA [1001]","HB CH AETNA HMO / PPO","1210.78","58.3","","464.71","67.87","1012.10","221","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1210.78","58.3","","293.04","293.04","293.04","11","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1100.71","53","","983.89","983.89","983.89","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1204.55","58","","677.18","677.18","677.18","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1298.01","62.5","","46.58","46.58","46.58","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1516.07","73","","747.15","747.15","747.15","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","923.14","44.45","","1141.67","481.21","1141.67","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","923.14","44.45","","76.54","76.54","76.54","1 through 10","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","WELLPOINT [1015]","HB CH WELLPOINT","1618.04","77.91","","273.64","94.28","1367.51","138","923.14","1618.04","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","1231.55","59.3","","720.78","230.14","2010.94","427","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1231.55","59.3","","344.45","344.45","344.45","1 through 10","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1629.26","78.45","","1120.13","1120.13","1120.13","1 through 10","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1629.26","78.45","","456.17","105.33","1284.66","242","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","AETNA [1001]","HB CH AETNA HMO / PPO","612.83","58.3","","464.71","67.87","1012.10","221","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.83","58.3","","293.04","293.04","293.04","11","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","557.12","53","","983.89","983.89","983.89","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","609.68","58","","677.18","677.18","677.18","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","656.98","62.5","","46.58","46.58","46.58","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","767.35","73","","747.15","747.15","747.15","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","467.25","44.45","","1141.67","481.21","1141.67","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","467.25","44.45","","76.54","76.54","76.54","1 through 10","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1051.17","788.38","WELLPOINT [1015]","HB CH WELLPOINT","818.97","77.91","","273.64","94.28","1367.51","138","467.25","818.97","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1051.17","788.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","623.34","59.3","","720.78","230.14","2010.94","427","525.59","824.64","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1051.17","788.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","623.34","59.3","","344.45","344.45","344.45","1 through 10","525.59","824.64","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1051.17","788.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","824.64","78.45","","1120.13","1120.13","1120.13","1 through 10","525.59","824.64","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1051.17","788.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","824.64","78.45","","456.17","105.33","1284.66","242","525.59","824.64","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","AETNA [1001]","HB CH AETNA HMO / PPO","741.61","58.3","","464.71","67.87","1012.10","221","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","741.61","58.3","","293.04","293.04","293.04","11","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","674.19","53","","983.89","983.89","983.89","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","737.79","58","","677.18","677.18","677.18","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","795.04","62.5","","46.58","46.58","46.58","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","928.60","73","","747.15","747.15","747.15","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.43","44.45","","1141.67","481.21","1141.67","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.43","44.45","","76.54","76.54","76.54","1 through 10","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","WELLPOINT [1015]","HB CH WELLPOINT","991.06","77.91","","273.64","94.28","1367.51","138","565.43","991.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","754.33","59.3","","720.78","230.14","2010.94","427","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","754.33","59.3","","344.45","344.45","344.45","1 through 10","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","997.93","78.45","","1120.13","1120.13","1120.13","1 through 10","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","997.93","78.45","","456.17","105.33","1284.66","242","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","AETNA [1001]","HB CH AETNA HMO / PPO","760.38","58.3","","464.71","67.87","1012.10","221","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","760.38","58.3","","293.04","293.04","293.04","11","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.25","53","","983.89","983.89","983.89","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","756.47","58","","677.18","677.18","677.18","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","815.16","62.5","","46.58","46.58","46.58","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","952.10","73","","747.15","747.15","747.15","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.74","44.45","","1141.67","481.21","1141.67","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.74","44.45","","76.54","76.54","76.54","1 through 10","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","WELLPOINT [1015]","HB CH WELLPOINT","1016.14","77.91","","273.64","94.28","1367.51","138","579.74","1016.14","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.42","59.3","","720.78","230.14","2010.94","427","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","773.42","59.3","","344.45","344.45","344.45","1 through 10","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1023.18","78.45","","1120.13","1120.13","1120.13","1 through 10","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.18","78.45","","456.17","105.33","1284.66","242","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","AETNA [1001]","HB CH AETNA HMO / PPO","543.59","58.3","","464.71","67.87","1012.10","221","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","543.59","58.3","","293.04","293.04","293.04","11","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","494.17","53","","983.89","983.89","983.89","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","540.79","58","","677.18","677.18","677.18","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","582.75","62.5","","46.58","46.58","46.58","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","680.65","73","","747.15","747.15","747.15","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.45","44.45","","1141.67","481.21","1141.67","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.45","44.45","","76.54","76.54","76.54","1 through 10","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","WELLPOINT [1015]","HB CH WELLPOINT","726.43","77.91","","273.64","94.28","1367.51","138","414.45","726.43","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","552.91","59.3","","720.78","230.14","2010.94","427","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","552.91","59.3","","344.45","344.45","344.45","1 through 10","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","731.47","78.45","","1120.13","1120.13","1120.13","1 through 10","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.47","78.45","","456.17","105.33","1284.66","242","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","AETNA [1001]","HB CH AETNA HMO / PPO","491.17","58.3","","464.71","67.87","1012.10","221","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","491.17","58.3","","293.04","293.04","293.04","11","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","446.52","53","","983.89","983.89","983.89","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","488.64","58","","677.18","677.18","677.18","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","526.56","62.5","","46.58","46.58","46.58","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","615.02","73","","747.15","747.15","747.15","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.49","44.45","","1141.67","481.21","1141.67","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.49","44.45","","76.54","76.54","76.54","1 through 10","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","WELLPOINT [1015]","HB CH WELLPOINT","656.38","77.91","","273.64","94.28","1367.51","138","374.49","656.38","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","499.60","59.3","","720.78","230.14","2010.94","427","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","499.60","59.3","","344.45","344.45","344.45","1 through 10","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","660.93","78.45","","1120.13","1120.13","1120.13","1 through 10","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","660.93","78.45","","456.17","105.33","1284.66","242","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","AETNA [1001]","HB CH AETNA HMO / PPO","645.84","58.3","","464.71","67.87","1012.10","221","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","645.84","58.3","","293.04","293.04","293.04","11","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","587.12","53","","983.89","983.89","983.89","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","642.51","58","","677.18","677.18","677.18","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","692.36","62.5","","46.58","46.58","46.58","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","808.68","73","","747.15","747.15","747.15","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.41","44.45","","1141.67","481.21","1141.67","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.41","44.45","","76.54","76.54","76.54","1 through 10","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","WELLPOINT [1015]","HB CH WELLPOINT","863.07","77.91","","273.64","94.28","1367.51","138","492.41","863.07","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","656.91","59.3","","720.78","230.14","2010.94","427","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","656.91","59.3","","344.45","344.45","344.45","1 through 10","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","869.05","78.45","","1120.13","1120.13","1120.13","1 through 10","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","869.05","78.45","","456.17","105.33","1284.66","242","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","AETNA [1001]","HB CH AETNA HMO / PPO","583.06","58.3","","464.71","67.87","1012.10","221","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","583.06","58.3","","293.04","293.04","293.04","11","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","530.06","53","","983.89","983.89","983.89","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","580.06","58","","677.18","677.18","677.18","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","625.07","62.5","","46.58","46.58","46.58","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","730.08","73","","747.15","747.15","747.15","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.55","44.45","","1141.67","481.21","1141.67","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.55","44.45","","76.54","76.54","76.54","1 through 10","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1000.11","750.08","WELLPOINT [1015]","HB CH WELLPOINT","779.19","77.91","","273.64","94.28","1367.51","138","444.55","779.19","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1000.11","750.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","593.07","59.3","","720.78","230.14","2010.94","427","500.06","784.59","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1000.11","750.08","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","593.07","59.3","","344.45","344.45","344.45","1 through 10","500.06","784.59","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1000.11","750.08","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","784.59","78.45","","1120.13","1120.13","1120.13","1 through 10","500.06","784.59","percent of total billed charges",""
"BONE PLATE 2MMX33 5 HOLE LC DCP SS","SUP-ITM-10038071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1000.11","750.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","784.59","78.45","","456.17","105.33","1284.66","242","500.06","784.59","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","AETNA [1001]","HB CH AETNA HMO / PPO","374.69","58.3","","464.71","67.87","1012.10","221","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","374.69","58.3","","293.04","293.04","293.04","11","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","340.63","53","","983.89","983.89","983.89","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","372.76","58","","677.18","677.18","677.18","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","401.68","62.5","","46.58","46.58","46.58","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","469.16","73","","747.15","747.15","747.15","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.68","44.45","","1141.67","481.21","1141.67","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.68","44.45","","76.54","76.54","76.54","1 through 10","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","WELLPOINT [1015]","HB CH WELLPOINT","500.72","77.91","","273.64","94.28","1367.51","138","285.68","500.72","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","381.12","59.3","","720.78","230.14","2010.94","427","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","381.12","59.3","","344.45","344.45","344.45","1 through 10","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","504.19","78.45","","1120.13","1120.13","1120.13","1 through 10","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","504.19","78.45","","456.17","105.33","1284.66","242","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","AETNA [1001]","HB CH AETNA HMO / PPO","82.19","58.3","","464.71","67.87","1012.10","221","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","82.19","58.3","","293.04","293.04","293.04","11","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","74.71","53","","983.89","983.89","983.89","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","81.76","58","","677.18","677.18","677.18","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","88.11","62.5","","46.58","46.58","46.58","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","102.91","73","","747.15","747.15","747.15","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.66","44.45","","1141.67","481.21","1141.67","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.66","44.45","","76.54","76.54","76.54","1 through 10","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","WELLPOINT [1015]","HB CH WELLPOINT","109.83","77.91","","273.64","94.28","1367.51","138","62.66","109.83","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.60","59.3","","720.78","230.14","2010.94","427","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","83.60","59.3","","344.45","344.45","344.45","1 through 10","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","110.59","78.45","","1120.13","1120.13","1120.13","1 through 10","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.59","78.45","","456.17","105.33","1284.66","242","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","AETNA [1001]","HB CH AETNA HMO / PPO","551.35","58.3","","464.71","67.87","1012.10","221","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","551.35","58.3","","293.04","293.04","293.04","11","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","501.23","53","","983.89","983.89","983.89","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.52","58","","677.18","677.18","677.18","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","591.08","62.5","","46.58","46.58","46.58","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","690.38","73","","747.15","747.15","747.15","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.37","44.45","","1141.67","481.21","1141.67","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.37","44.45","","76.54","76.54","76.54","1 through 10","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","WELLPOINT [1015]","HB CH WELLPOINT","736.81","77.91","","273.64","94.28","1367.51","138","420.37","736.81","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.81","59.3","","720.78","230.14","2010.94","427","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.81","59.3","","344.45","344.45","344.45","1 through 10","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","741.92","78.45","","1120.13","1120.13","1120.13","1 through 10","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.92","78.45","","456.17","105.33","1284.66","242","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","AETNA [1001]","HB CH AETNA HMO / PPO","641.31","58.3","","464.71","67.87","1012.10","221","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","641.31","58.3","","293.04","293.04","293.04","11","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","583.01","53","","983.89","983.89","983.89","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","638.01","58","","677.18","677.18","677.18","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","687.51","62.5","","46.58","46.58","46.58","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","803.01","73","","747.15","747.15","747.15","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.95","44.45","","1141.67","481.21","1141.67","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.95","44.45","","76.54","76.54","76.54","1 through 10","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","WELLPOINT [1015]","HB CH WELLPOINT","857.02","77.91","","273.64","94.28","1367.51","138","488.95","857.02","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","652.31","59.3","","720.78","230.14","2010.94","427","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","652.31","59.3","","344.45","344.45","344.45","1 through 10","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","862.96","78.45","","1120.13","1120.13","1120.13","1 through 10","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.96","78.45","","456.17","105.33","1284.66","242","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","AETNA [1001]","HB CH AETNA HMO / PPO","643.89","58.3","","464.71","67.87","1012.10","221","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","643.89","58.3","","293.04","293.04","293.04","11","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","585.36","53","","983.89","983.89","983.89","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","640.58","58","","677.18","677.18","677.18","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","690.28","62.5","","46.58","46.58","46.58","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","806.25","73","","747.15","747.15","747.15","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","490.93","44.45","","1141.67","481.21","1141.67","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","490.93","44.45","","76.54","76.54","76.54","1 through 10","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","WELLPOINT [1015]","HB CH WELLPOINT","860.48","77.91","","273.64","94.28","1367.51","138","490.93","860.48","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","654.94","59.3","","720.78","230.14","2010.94","427","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","654.94","59.3","","344.45","344.45","344.45","1 through 10","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","866.44","78.45","","1120.13","1120.13","1120.13","1 through 10","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","866.44","78.45","","456.17","105.33","1284.66","242","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","AETNA [1001]","HB CH AETNA HMO / PPO","540.35","58.3","","464.71","67.87","1012.10","221","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","540.35","58.3","","293.04","293.04","293.04","11","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","491.23","53","","983.89","983.89","983.89","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","537.57","58","","677.18","677.18","677.18","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","579.28","62.5","","46.58","46.58","46.58","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","676.60","73","","747.15","747.15","747.15","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.98","44.45","","1141.67","481.21","1141.67","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.98","44.45","","76.54","76.54","76.54","1 through 10","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","WELLPOINT [1015]","HB CH WELLPOINT","722.11","77.91","","273.64","94.28","1367.51","138","411.98","722.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","549.62","59.3","","720.78","230.14","2010.94","427","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","549.62","59.3","","344.45","344.45","344.45","1 through 10","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","727.11","78.45","","1120.13","1120.13","1120.13","1 through 10","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","727.11","78.45","","456.17","105.33","1284.66","242","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","AETNA [1001]","HB CH AETNA HMO / PPO","738.38","58.3","","464.71","67.87","1012.10","221","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","738.38","58.3","","293.04","293.04","293.04","11","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","671.25","53","","983.89","983.89","983.89","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","734.58","58","","677.18","677.18","677.18","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","791.57","62.5","","46.58","46.58","46.58","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","924.55","73","","747.15","747.15","747.15","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.96","44.45","","1141.67","481.21","1141.67","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.96","44.45","","76.54","76.54","76.54","1 through 10","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","WELLPOINT [1015]","HB CH WELLPOINT","986.74","77.91","","273.64","94.28","1367.51","138","562.96","986.74","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","751.04","59.3","","720.78","230.14","2010.94","427","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","751.04","59.3","","344.45","344.45","344.45","1 through 10","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","993.58","78.45","","1120.13","1120.13","1120.13","1 through 10","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","993.58","78.45","","456.17","105.33","1284.66","242","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","AETNA [1001]","HB CH AETNA HMO / PPO","308.03","58.3","","464.71","67.87","1012.10","221","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","308.03","58.3","","293.04","293.04","293.04","11","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","280.03","53","","983.89","983.89","983.89","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","306.45","58","","677.18","677.18","677.18","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","330.23","62.5","","46.58","46.58","46.58","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","385.70","73","","747.15","747.15","747.15","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.86","44.45","","1141.67","481.21","1141.67","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.86","44.45","","76.54","76.54","76.54","1 through 10","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","WELLPOINT [1015]","HB CH WELLPOINT","411.65","77.91","","273.64","94.28","1367.51","138","234.86","411.65","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","313.32","59.3","","720.78","230.14","2010.94","427","264.18","414.5","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","313.32","59.3","","344.45","344.45","344.45","1 through 10","264.18","414.5","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","414.50","78.45","","1120.13","1120.13","1120.13","1 through 10","264.18","414.5","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","414.50","78.45","","456.17","105.33","1284.66","242","264.18","414.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","AETNA [1001]","HB CH AETNA HMO / PPO","436.17","58.3","","464.71","67.87","1012.10","221","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","436.17","58.3","","293.04","293.04","293.04","11","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","396.51","53","","983.89","983.89","983.89","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","433.92","58","","677.18","677.18","677.18","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","467.59","62.5","","46.58","46.58","46.58","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","546.14","73","","747.15","747.15","747.15","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.55","44.45","","1141.67","481.21","1141.67","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.55","44.45","","76.54","76.54","76.54","1 through 10","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","WELLPOINT [1015]","HB CH WELLPOINT","582.88","77.91","","273.64","94.28","1367.51","138","332.55","582.88","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","443.65","59.3","","720.78","230.14","2010.94","427","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","443.65","59.3","","344.45","344.45","344.45","1 through 10","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","586.92","78.45","","1120.13","1120.13","1120.13","1 through 10","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","586.92","78.45","","456.17","105.33","1284.66","242","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","AETNA [1001]","HB CH AETNA HMO / PPO","422.58","58.3","","464.71","67.87","1012.10","221","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","422.58","58.3","","293.04","293.04","293.04","11","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","384.16","53","","983.89","983.89","983.89","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","420.40","58","","677.18","677.18","677.18","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","453.02","62.5","","46.58","46.58","46.58","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","529.13","73","","747.15","747.15","747.15","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.19","44.45","","1141.67","481.21","1141.67","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.19","44.45","","76.54","76.54","76.54","1 through 10","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","724.83","543.62","WELLPOINT [1015]","HB CH WELLPOINT","564.72","77.91","","273.64","94.28","1367.51","138","322.19","564.72","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","724.83","543.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","429.82","59.3","","720.78","230.14","2010.94","427","362.42","568.63","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","724.83","543.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","429.82","59.3","","344.45","344.45","344.45","1 through 10","362.42","568.63","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","724.83","543.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","568.63","78.45","","1120.13","1120.13","1120.13","1 through 10","362.42","568.63","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","724.83","543.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","568.63","78.45","","456.17","105.33","1284.66","242","362.42","568.63","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","AETNA [1001]","HB CH AETNA HMO / PPO","458.17","58.3","","464.71","67.87","1012.10","221","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","458.17","58.3","","293.04","293.04","293.04","11","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","416.52","53","","983.89","983.89","983.89","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","455.81","58","","677.18","677.18","677.18","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","491.18","62.5","","46.58","46.58","46.58","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","573.69","73","","747.15","747.15","747.15","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.32","44.45","","1141.67","481.21","1141.67","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.32","44.45","","76.54","76.54","76.54","1 through 10","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","WELLPOINT [1015]","HB CH WELLPOINT","612.28","77.91","","273.64","94.28","1367.51","138","349.32","612.28","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","466.03","59.3","","720.78","230.14","2010.94","427","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","466.03","59.3","","344.45","344.45","344.45","1 through 10","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","616.52","78.45","","1120.13","1120.13","1120.13","1 through 10","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","616.52","78.45","","456.17","105.33","1284.66","242","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","AETNA [1001]","HB CH AETNA HMO / PPO","476.93","58.3","","464.71","67.87","1012.10","221","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","476.93","58.3","","293.04","293.04","293.04","11","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","433.58","53","","983.89","983.89","983.89","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","474.48","58","","677.18","677.18","677.18","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","511.29","62.5","","46.58","46.58","46.58","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","597.19","73","","747.15","747.15","747.15","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.63","44.45","","1141.67","481.21","1141.67","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.63","44.45","","76.54","76.54","76.54","1 through 10","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","WELLPOINT [1015]","HB CH WELLPOINT","637.36","77.91","","273.64","94.28","1367.51","138","363.63","637.36","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.12","59.3","","720.78","230.14","2010.94","427","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","485.12","59.3","","344.45","344.45","344.45","1 through 10","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","641.78","78.45","","1120.13","1120.13","1120.13","1 through 10","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","641.78","78.45","","456.17","105.33","1284.66","242","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","AETNA [1001]","HB CH AETNA HMO / PPO","533.88","58.3","","464.71","67.87","1012.10","221","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","533.88","58.3","","293.04","293.04","293.04","11","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","485.35","53","","983.89","983.89","983.89","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","531.14","58","","677.18","677.18","677.18","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","572.34","62.5","","46.58","46.58","46.58","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","668.50","73","","747.15","747.15","747.15","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.05","44.45","","1141.67","481.21","1141.67","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.05","44.45","","76.54","76.54","76.54","1 through 10","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","915.75","686.81","WELLPOINT [1015]","HB CH WELLPOINT","713.46","77.91","","273.64","94.28","1367.51","138","407.05","713.46","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","915.75","686.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","543.04","59.3","","720.78","230.14","2010.94","427","457.88","718.41","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","915.75","686.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","543.04","59.3","","344.45","344.45","344.45","1 through 10","457.88","718.41","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","915.75","686.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","718.41","78.45","","1120.13","1120.13","1120.13","1 through 10","457.88","718.41","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","915.75","686.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","718.41","78.45","","456.17","105.33","1284.66","242","457.88","718.41","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","AETNA [1001]","HB CH AETNA HMO / PPO","468.52","58.3","","464.71","67.87","1012.10","221","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","468.52","58.3","","293.04","293.04","293.04","11","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","425.93","53","","983.89","983.89","983.89","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","466.11","58","","677.18","677.18","677.18","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","502.28","62.5","","46.58","46.58","46.58","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","586.66","73","","747.15","747.15","747.15","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","357.22","44.45","","1141.67","481.21","1141.67","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","357.22","44.45","","76.54","76.54","76.54","1 through 10","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","WELLPOINT [1015]","HB CH WELLPOINT","626.12","77.91","","273.64","94.28","1367.51","138","357.22","626.12","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","476.56","59.3","","720.78","230.14","2010.94","427","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","476.56","59.3","","344.45","344.45","344.45","1 through 10","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","630.46","78.45","","1120.13","1120.13","1120.13","1 through 10","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","630.46","78.45","","456.17","105.33","1284.66","242","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","AETNA [1001]","HB CH AETNA HMO / PPO","711.20","58.3","","464.71","67.87","1012.10","221","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","711.20","58.3","","293.04","293.04","293.04","11","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","646.54","53","","983.89","983.89","983.89","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","707.54","58","","677.18","677.18","677.18","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","762.43","62.5","","46.58","46.58","46.58","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","890.52","73","","747.15","747.15","747.15","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","542.24","44.45","","1141.67","481.21","1141.67","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","542.24","44.45","","76.54","76.54","76.54","1 through 10","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","WELLPOINT [1015]","HB CH WELLPOINT","950.42","77.91","","273.64","94.28","1367.51","138","542.24","950.42","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","723.39","59.3","","720.78","230.14","2010.94","427","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","723.39","59.3","","344.45","344.45","344.45","1 through 10","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","957.00","78.45","","1120.13","1120.13","1120.13","1 through 10","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","957.00","78.45","","456.17","105.33","1284.66","242","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","AETNA [1001]","HB CH AETNA HMO / PPO","541.65","58.3","","464.71","67.87","1012.10","221","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","541.65","58.3","","293.04","293.04","293.04","11","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","492.41","53","","983.89","983.89","983.89","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","538.86","58","","677.18","677.18","677.18","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","580.67","62.5","","46.58","46.58","46.58","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","678.22","73","","747.15","747.15","747.15","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.97","44.45","","1141.67","481.21","1141.67","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.97","44.45","","76.54","76.54","76.54","1 through 10","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.07","696.80","WELLPOINT [1015]","HB CH WELLPOINT","723.84","77.91","","273.64","94.28","1367.51","138","412.97","723.84","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.07","696.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","550.94","59.3","","720.78","230.14","2010.94","427","464.54","728.86","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.07","696.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","550.94","59.3","","344.45","344.45","344.45","1 through 10","464.54","728.86","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.07","696.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","728.86","78.45","","1120.13","1120.13","1120.13","1 through 10","464.54","728.86","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.07","696.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","728.86","78.45","","456.17","105.33","1284.66","242","464.54","728.86","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","AETNA [1001]","HB CH AETNA HMO / PPO","518.35","58.3","","464.71","67.87","1012.10","221","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","518.35","58.3","","293.04","293.04","293.04","11","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","471.23","53","","983.89","983.89","983.89","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","515.68","58","","677.18","677.18","677.18","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","555.69","62.5","","46.58","46.58","46.58","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","649.05","73","","747.15","747.15","747.15","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.21","44.45","","1141.67","481.21","1141.67","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.21","44.45","","76.54","76.54","76.54","1 through 10","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","WELLPOINT [1015]","HB CH WELLPOINT","692.71","77.91","","273.64","94.28","1367.51","138","395.21","692.71","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","527.24","59.3","","720.78","230.14","2010.94","427","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","527.24","59.3","","344.45","344.45","344.45","1 through 10","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","697.51","78.45","","1120.13","1120.13","1120.13","1 through 10","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","697.51","78.45","","456.17","105.33","1284.66","242","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","AETNA [1001]","HB CH AETNA HMO / PPO","787.56","58.3","","464.71","67.87","1012.10","221","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","787.56","58.3","","293.04","293.04","293.04","11","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.96","53","","983.89","983.89","983.89","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","783.50","58","","677.18","677.18","677.18","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","844.29","62.5","","46.58","46.58","46.58","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","986.14","73","","747.15","747.15","747.15","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.46","44.45","","1141.67","481.21","1141.67","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.46","44.45","","76.54","76.54","76.54","1 through 10","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","WELLPOINT [1015]","HB CH WELLPOINT","1052.46","77.91","","273.64","94.28","1367.51","138","600.46","1052.46","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","801.07","59.3","","720.78","230.14","2010.94","427","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","801.07","59.3","","344.45","344.45","344.45","1 through 10","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1059.76","78.45","","1120.13","1120.13","1120.13","1 through 10","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.76","78.45","","456.17","105.33","1284.66","242","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","AETNA [1001]","HB CH AETNA HMO / PPO","779.79","58.3","","464.71","67.87","1012.10","221","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","779.79","58.3","","293.04","293.04","293.04","11","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","708.90","53","","983.89","983.89","983.89","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","775.78","58","","677.18","677.18","677.18","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","835.97","62.5","","46.58","46.58","46.58","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.41","73","","747.15","747.15","747.15","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.54","44.45","","1141.67","481.21","1141.67","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.54","44.45","","76.54","76.54","76.54","1 through 10","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","WELLPOINT [1015]","HB CH WELLPOINT","1042.09","77.91","","273.64","94.28","1367.51","138","594.54","1042.09","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.17","59.3","","720.78","230.14","2010.94","427","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","793.17","59.3","","344.45","344.45","344.45","1 through 10","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1049.31","78.45","","1120.13","1120.13","1120.13","1 through 10","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.31","78.45","","456.17","105.33","1284.66","242","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","AETNA [1001]","HB CH AETNA HMO / PPO","2083.69","58.3","","464.71","67.87","1012.10","221","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2083.69","58.3","","293.04","293.04","293.04","11","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1894.26","53","","983.89","983.89","983.89","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2072.97","58","","677.18","677.18","677.18","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2233.80","62.5","","46.58","46.58","46.58","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2609.08","73","","747.15","747.15","747.15","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1588.68","44.45","","1141.67","481.21","1141.67","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1588.68","44.45","","76.54","76.54","76.54","1 through 10","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","WELLPOINT [1015]","HB CH WELLPOINT","2784.57","77.91","","273.64","94.28","1367.51","138","1588.68","2784.57","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2119.43","59.3","","720.78","230.14","2010.94","427","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2119.43","59.3","","344.45","344.45","344.45","1 through 10","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2803.87","78.45","","1120.13","1120.13","1120.13","1 through 10","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2803.87","78.45","","456.17","105.33","1284.66","242","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","AETNA [1001]","HB CH AETNA HMO / PPO","181.20","58.3","","464.71","67.87","1012.10","221","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.20","58.3","","293.04","293.04","293.04","11","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","164.72","53","","983.89","983.89","983.89","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","180.26","58","","677.18","677.18","677.18","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","194.25","62.5","","46.58","46.58","46.58","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","226.88","73","","747.15","747.15","747.15","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.15","44.45","","1141.67","481.21","1141.67","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.15","44.45","","76.54","76.54","76.54","1 through 10","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","WELLPOINT [1015]","HB CH WELLPOINT","242.14","77.91","","273.64","94.28","1367.51","138","138.15","242.14","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","184.30","59.3","","720.78","230.14","2010.94","427","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","184.30","59.3","","344.45","344.45","344.45","1 through 10","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","243.82","78.45","","1120.13","1120.13","1120.13","1 through 10","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","243.82","78.45","","456.17","105.33","1284.66","242","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","AETNA [1001]","HB CH AETNA HMO / PPO","185.73","58.3","","464.71","67.87","1012.10","221","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.73","58.3","","293.04","293.04","293.04","11","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.84","53","","983.89","983.89","983.89","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.77","58","","677.18","677.18","677.18","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","199.11","62.5","","46.58","46.58","46.58","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.56","73","","747.15","747.15","747.15","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.60","44.45","","1141.67","481.21","1141.67","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.60","44.45","","76.54","76.54","76.54","1 through 10","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","WELLPOINT [1015]","HB CH WELLPOINT","248.20","77.91","","273.64","94.28","1367.51","138","141.6","248.2","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.91","59.3","","720.78","230.14","2010.94","427","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.91","59.3","","344.45","344.45","344.45","1 through 10","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","249.92","78.45","","1120.13","1120.13","1120.13","1 through 10","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.92","78.45","","456.17","105.33","1284.66","242","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","AETNA [1001]","HB CH AETNA HMO / PPO","214.85","58.3","","464.71","67.87","1012.10","221","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","214.85","58.3","","293.04","293.04","293.04","11","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","195.32","53","","983.89","983.89","983.89","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","213.74","58","","677.18","677.18","677.18","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","230.33","62.5","","46.58","46.58","46.58","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","269.02","73","","747.15","747.15","747.15","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.81","44.45","","1141.67","481.21","1141.67","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.81","44.45","","76.54","76.54","76.54","1 through 10","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","WELLPOINT [1015]","HB CH WELLPOINT","287.11","77.91","","273.64","94.28","1367.51","138","163.81","287.11","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","218.53","59.3","","720.78","230.14","2010.94","427","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","218.53","59.3","","344.45","344.45","344.45","1 through 10","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","289.10","78.45","","1120.13","1120.13","1120.13","1 through 10","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","289.10","78.45","","456.17","105.33","1284.66","242","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","AETNA [1001]","HB CH AETNA HMO / PPO","396.04","58.3","","464.71","67.87","1012.10","221","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","396.04","58.3","","293.04","293.04","293.04","11","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","360.04","53","","983.89","983.89","983.89","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","394.01","58","","677.18","677.18","677.18","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","424.58","62.5","","46.58","46.58","46.58","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","495.90","73","","747.15","747.15","747.15","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.96","44.45","","1141.67","481.21","1141.67","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.96","44.45","","76.54","76.54","76.54","1 through 10","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","WELLPOINT [1015]","HB CH WELLPOINT","529.26","77.91","","273.64","94.28","1367.51","138","301.96","529.26","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","402.84","59.3","","720.78","230.14","2010.94","427","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","402.84","59.3","","344.45","344.45","344.45","1 through 10","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","532.93","78.45","","1120.13","1120.13","1120.13","1 through 10","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","532.93","78.45","","456.17","105.33","1284.66","242","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","AETNA [1001]","HB CH AETNA HMO / PPO","445.23","58.3","","464.71","67.87","1012.10","221","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","445.23","58.3","","293.04","293.04","293.04","11","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.75","53","","983.89","983.89","983.89","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","442.93","58","","677.18","677.18","677.18","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","477.30","62.5","","46.58","46.58","46.58","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","557.49","73","","747.15","747.15","747.15","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.46","44.45","","1141.67","481.21","1141.67","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.46","44.45","","76.54","76.54","76.54","1 through 10","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","WELLPOINT [1015]","HB CH WELLPOINT","594.98","77.91","","273.64","94.28","1367.51","138","339.46","594.98","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","452.86","59.3","","720.78","230.14","2010.94","427","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","452.86","59.3","","344.45","344.45","344.45","1 through 10","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","599.11","78.45","","1120.13","1120.13","1120.13","1 through 10","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","599.11","78.45","","456.17","105.33","1284.66","242","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","AETNA [1001]","HB CH AETNA HMO / PPO","437.46","58.3","","464.71","67.87","1012.10","221","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.46","58.3","","293.04","293.04","293.04","11","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.69","53","","983.89","983.89","983.89","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.21","58","","677.18","677.18","677.18","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.98","62.5","","46.58","46.58","46.58","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.76","73","","747.15","747.15","747.15","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.54","44.45","","1141.67","481.21","1141.67","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.54","44.45","","76.54","76.54","76.54","1 through 10","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.36","562.77","WELLPOINT [1015]","HB CH WELLPOINT","584.61","77.91","","273.64","94.28","1367.51","138","333.54","584.61","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.36","562.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.96","59.3","","720.78","230.14","2010.94","427","375.18","588.66","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.36","562.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.96","59.3","","344.45","344.45","344.45","1 through 10","375.18","588.66","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.36","562.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.66","78.45","","1120.13","1120.13","1120.13","1 through 10","375.18","588.66","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.36","562.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.66","78.45","","456.17","105.33","1284.66","242","375.18","588.66","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","AETNA [1001]","HB CH AETNA HMO / PPO","409.63","58.3","","464.71","67.87","1012.10","221","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.63","58.3","","293.04","293.04","293.04","11","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.39","53","","983.89","983.89","983.89","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","407.53","58","","677.18","677.18","677.18","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","439.14","62.5","","46.58","46.58","46.58","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","747.15","747.15","747.15","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","1141.67","481.21","1141.67","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","76.54","76.54","76.54","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","WELLPOINT [1015]","HB CH WELLPOINT","547.42","77.91","","273.64","94.28","1367.51","138","312.32","547.42","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.66","59.3","","720.78","230.14","2010.94","427","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","416.66","59.3","","344.45","344.45","344.45","1 through 10","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","1120.13","1120.13","1120.13","1 through 10","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","456.17","105.33","1284.66","242","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","AETNA [1001]","HB CH AETNA HMO / PPO","465.93","58.3","","464.71","67.87","1012.10","221","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","465.93","58.3","","293.04","293.04","293.04","11","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","423.58","53","","983.89","983.89","983.89","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","463.54","58","","677.18","677.18","677.18","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","499.50","62.5","","46.58","46.58","46.58","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","583.42","73","","747.15","747.15","747.15","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.24","44.45","","1141.67","481.21","1141.67","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.24","44.45","","76.54","76.54","76.54","1 through 10","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","WELLPOINT [1015]","HB CH WELLPOINT","622.66","77.91","","273.64","94.28","1367.51","138","355.24","622.66","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","473.93","59.3","","720.78","230.14","2010.94","427","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","473.93","59.3","","344.45","344.45","344.45","1 through 10","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","626.97","78.45","","1120.13","1120.13","1120.13","1 through 10","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","626.97","78.45","","456.17","105.33","1284.66","242","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","AETNA [1001]","HB CH AETNA HMO / PPO","449.11","58.3","","464.71","67.87","1012.10","221","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","449.11","58.3","","293.04","293.04","293.04","11","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","408.28","53","","983.89","983.89","983.89","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","446.80","58","","677.18","677.18","677.18","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","481.46","62.5","","46.58","46.58","46.58","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","747.15","747.15","747.15","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.42","44.45","","1141.67","481.21","1141.67","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.42","44.45","","76.54","76.54","76.54","1 through 10","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","WELLPOINT [1015]","HB CH WELLPOINT","600.17","77.91","","273.64","94.28","1367.51","138","342.42","600.17","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","456.81","59.3","","720.78","230.14","2010.94","427","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","456.81","59.3","","344.45","344.45","344.45","1 through 10","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","604.33","78.45","","1120.13","1120.13","1120.13","1 through 10","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","604.33","78.45","","456.17","105.33","1284.66","242","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","AETNA [1001]","HB CH AETNA HMO / PPO","542.29","58.3","","464.71","67.87","1012.10","221","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","542.29","58.3","","293.04","293.04","293.04","11","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","493.00","53","","983.89","983.89","983.89","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","539.50","58","","677.18","677.18","677.18","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","581.36","62.5","","46.58","46.58","46.58","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","679.03","73","","747.15","747.15","747.15","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.47","44.45","","1141.67","481.21","1141.67","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.47","44.45","","76.54","76.54","76.54","1 through 10","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","WELLPOINT [1015]","HB CH WELLPOINT","724.70","77.91","","273.64","94.28","1367.51","138","413.47","724.7","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","551.60","59.3","","720.78","230.14","2010.94","427","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","551.60","59.3","","344.45","344.45","344.45","1 through 10","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","729.73","78.45","","1120.13","1120.13","1120.13","1 through 10","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","729.73","78.45","","456.17","105.33","1284.66","242","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","AETNA [1001]","HB CH AETNA HMO / PPO","377.92","58.3","","464.71","67.87","1012.10","221","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","377.92","58.3","","293.04","293.04","293.04","11","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","343.57","53","","983.89","983.89","983.89","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","375.98","58","","677.18","677.18","677.18","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","405.15","62.5","","46.58","46.58","46.58","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","473.22","73","","747.15","747.15","747.15","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.14","44.45","","1141.67","481.21","1141.67","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.14","44.45","","76.54","76.54","76.54","1 through 10","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","WELLPOINT [1015]","HB CH WELLPOINT","505.04","77.91","","273.64","94.28","1367.51","138","288.14","505.04","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","384.41","59.3","","720.78","230.14","2010.94","427","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","384.41","59.3","","344.45","344.45","344.45","1 through 10","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","508.54","78.45","","1120.13","1120.13","1120.13","1 through 10","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","508.54","78.45","","456.17","105.33","1284.66","242","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","AETNA [1001]","HB CH AETNA HMO / PPO","138.71","58.3","","464.71","67.87","1012.10","221","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.71","58.3","","293.04","293.04","293.04","11","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.10","53","","983.89","983.89","983.89","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","138.00","58","","677.18","677.18","677.18","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.71","62.5","","46.58","46.58","46.58","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","747.15","747.15","747.15","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","1141.67","481.21","1141.67","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","76.54","76.54","76.54","1 through 10","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","WELLPOINT [1015]","HB CH WELLPOINT","185.37","77.91","","273.64","94.28","1367.51","138","105.76","185.37","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.09","59.3","","720.78","230.14","2010.94","427","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","141.09","59.3","","344.45","344.45","344.45","1 through 10","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","1120.13","1120.13","1120.13","1 through 10","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","456.17","105.33","1284.66","242","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","AETNA [1001]","HB CH AETNA HMO / PPO","139.15","58.3","","464.71","67.87","1012.10","221","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.15","58.3","","293.04","293.04","293.04","11","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.50","53","","983.89","983.89","983.89","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","138.43","58","","677.18","677.18","677.18","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","149.18","62.5","","46.58","46.58","46.58","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","174.24","73","","747.15","747.15","747.15","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.09","44.45","","1141.67","481.21","1141.67","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.09","44.45","","76.54","76.54","76.54","1 through 10","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","WELLPOINT [1015]","HB CH WELLPOINT","185.96","77.91","","273.64","94.28","1367.51","138","106.09","185.96","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.54","59.3","","720.78","230.14","2010.94","427","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","141.54","59.3","","344.45","344.45","344.45","1 through 10","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","187.24","78.45","","1120.13","1120.13","1120.13","1 through 10","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","187.24","78.45","","456.17","105.33","1284.66","242","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","AETNA [1001]","HB CH AETNA HMO / PPO","456.23","58.3","","464.71","67.87","1012.10","221","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","456.23","58.3","","293.04","293.04","293.04","11","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","414.75","53","","983.89","983.89","983.89","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","453.88","58","","677.18","677.18","677.18","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","489.09","62.5","","46.58","46.58","46.58","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","571.26","73","","747.15","747.15","747.15","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.84","44.45","","1141.67","481.21","1141.67","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.84","44.45","","76.54","76.54","76.54","1 through 10","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","WELLPOINT [1015]","HB CH WELLPOINT","609.68","77.91","","273.64","94.28","1367.51","138","347.84","609.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","464.05","59.3","","720.78","230.14","2010.94","427","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","464.05","59.3","","344.45","344.45","344.45","1 through 10","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","613.91","78.45","","1120.13","1120.13","1120.13","1 through 10","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","613.91","78.45","","456.17","105.33","1284.66","242","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","AETNA [1001]","HB CH AETNA HMO / PPO","486.64","58.3","","464.71","67.87","1012.10","221","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","486.64","58.3","","293.04","293.04","293.04","11","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","442.40","53","","983.89","983.89","983.89","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","484.14","58","","677.18","677.18","677.18","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","521.70","62.5","","46.58","46.58","46.58","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","609.35","73","","747.15","747.15","747.15","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.03","44.45","","1141.67","481.21","1141.67","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.03","44.45","","76.54","76.54","76.54","1 through 10","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","WELLPOINT [1015]","HB CH WELLPOINT","650.33","77.91","","273.64","94.28","1367.51","138","371.03","650.33","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","494.99","59.3","","720.78","230.14","2010.94","427","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","494.99","59.3","","344.45","344.45","344.45","1 through 10","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","654.84","78.45","","1120.13","1120.13","1120.13","1 through 10","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","654.84","78.45","","456.17","105.33","1284.66","242","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","AETNA [1001]","HB CH AETNA HMO / PPO","419.99","58.3","","464.71","67.87","1012.10","221","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.99","58.3","","293.04","293.04","293.04","11","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.81","53","","983.89","983.89","983.89","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.83","58","","677.18","677.18","677.18","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.24","62.5","","46.58","46.58","46.58","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.88","73","","747.15","747.15","747.15","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.21","44.45","","1141.67","481.21","1141.67","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.21","44.45","","76.54","76.54","76.54","1 through 10","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","WELLPOINT [1015]","HB CH WELLPOINT","561.26","77.91","","273.64","94.28","1367.51","138","320.21","561.26","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","427.19","59.3","","720.78","230.14","2010.94","427","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","427.19","59.3","","344.45","344.45","344.45","1 through 10","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","565.15","78.45","","1120.13","1120.13","1120.13","1 through 10","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","565.15","78.45","","456.17","105.33","1284.66","242","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","AETNA [1001]","HB CH AETNA HMO / PPO","524.82","58.3","","464.71","67.87","1012.10","221","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.82","58.3","","293.04","293.04","293.04","11","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.11","53","","983.89","983.89","983.89","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.12","58","","677.18","677.18","677.18","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.63","62.5","","46.58","46.58","46.58","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.15","73","","747.15","747.15","747.15","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.14","44.45","","1141.67","481.21","1141.67","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.14","44.45","","76.54","76.54","76.54","1 through 10","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","WELLPOINT [1015]","HB CH WELLPOINT","701.35","77.91","","273.64","94.28","1367.51","138","400.14","701.35","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.82","59.3","","720.78","230.14","2010.94","427","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.82","59.3","","344.45","344.45","344.45","1 through 10","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","706.21","78.45","","1120.13","1120.13","1120.13","1 through 10","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.21","78.45","","456.17","105.33","1284.66","242","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","AETNA [1001]","HB CH AETNA HMO / PPO","626.42","58.3","","464.71","67.87","1012.10","221","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","626.42","58.3","","293.04","293.04","293.04","11","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","569.47","53","","983.89","983.89","983.89","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","623.20","58","","677.18","677.18","677.18","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","671.55","62.5","","46.58","46.58","46.58","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","784.37","73","","747.15","747.15","747.15","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.61","44.45","","1141.67","481.21","1141.67","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.61","44.45","","76.54","76.54","76.54","1 through 10","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","WELLPOINT [1015]","HB CH WELLPOINT","837.13","77.91","","273.64","94.28","1367.51","138","477.61","837.13","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","637.17","59.3","","720.78","230.14","2010.94","427","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","637.17","59.3","","344.45","344.45","344.45","1 through 10","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","842.93","78.45","","1120.13","1120.13","1120.13","1 through 10","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","842.93","78.45","","456.17","105.33","1284.66","242","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","AETNA [1001]","HB CH AETNA HMO / PPO","656.19","58.3","","464.71","67.87","1012.10","221","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.19","58.3","","293.04","293.04","293.04","11","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.54","53","","983.89","983.89","983.89","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.81","58","","677.18","677.18","677.18","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.46","62.5","","46.58","46.58","46.58","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","747.15","747.15","747.15","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.30","44.45","","1141.67","481.21","1141.67","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.30","44.45","","76.54","76.54","76.54","1 through 10","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","WELLPOINT [1015]","HB CH WELLPOINT","876.91","77.91","","273.64","94.28","1367.51","138","500.3","876.91","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.45","59.3","","720.78","230.14","2010.94","427","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.45","59.3","","344.45","344.45","344.45","1 through 10","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.99","78.45","","1120.13","1120.13","1120.13","1 through 10","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.99","78.45","","456.17","105.33","1284.66","242","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","AETNA [1001]","HB CH AETNA HMO / PPO","527.41","58.3","","464.71","67.87","1012.10","221","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","527.41","58.3","","293.04","293.04","293.04","11","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","479.46","53","","983.89","983.89","983.89","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","524.70","58","","677.18","677.18","677.18","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","565.41","62.5","","46.58","46.58","46.58","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","660.39","73","","747.15","747.15","747.15","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.12","44.45","","1141.67","481.21","1141.67","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.12","44.45","","76.54","76.54","76.54","1 through 10","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","WELLPOINT [1015]","HB CH WELLPOINT","704.81","77.91","","273.64","94.28","1367.51","138","402.12","704.81","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","536.46","59.3","","720.78","230.14","2010.94","427","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","536.46","59.3","","344.45","344.45","344.45","1 through 10","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","709.70","78.45","","1120.13","1120.13","1120.13","1 through 10","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","709.70","78.45","","456.17","105.33","1284.66","242","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","AETNA [1001]","HB CH AETNA HMO / PPO","656.84","58.3","","464.71","67.87","1012.10","221","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.84","58.3","","293.04","293.04","293.04","11","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","597.12","53","","983.89","983.89","983.89","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","653.46","58","","677.18","677.18","677.18","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","704.16","62.5","","46.58","46.58","46.58","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","822.45","73","","747.15","747.15","747.15","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.80","44.45","","1141.67","481.21","1141.67","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.80","44.45","","76.54","76.54","76.54","1 through 10","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","WELLPOINT [1015]","HB CH WELLPOINT","877.77","77.91","","273.64","94.28","1367.51","138","500.8","877.77","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","668.10","59.3","","720.78","230.14","2010.94","427","563.33","883.86","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","668.10","59.3","","344.45","344.45","344.45","1 through 10","563.33","883.86","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","883.86","78.45","","1120.13","1120.13","1120.13","1 through 10","563.33","883.86","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","883.86","78.45","","456.17","105.33","1284.66","242","563.33","883.86","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","AETNA [1001]","HB CH AETNA HMO / PPO","517.06","58.3","","464.71","67.87","1012.10","221","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","517.06","58.3","","293.04","293.04","293.04","11","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","470.05","53","","983.89","983.89","983.89","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","514.40","58","","677.18","677.18","677.18","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","554.31","62.5","","46.58","46.58","46.58","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","647.43","73","","747.15","747.15","747.15","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.22","44.45","","1141.67","481.21","1141.67","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.22","44.45","","76.54","76.54","76.54","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","WELLPOINT [1015]","HB CH WELLPOINT","690.98","77.91","","273.64","94.28","1367.51","138","394.22","690.98","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","525.93","59.3","","720.78","230.14","2010.94","427","443.45","695.77","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","525.93","59.3","","344.45","344.45","344.45","1 through 10","443.45","695.77","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","695.77","78.45","","1120.13","1120.13","1120.13","1 through 10","443.45","695.77","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","695.77","78.45","","456.17","105.33","1284.66","242","443.45","695.77","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","AETNA [1001]","HB CH AETNA HMO / PPO","204.49","58.3","","464.71","67.87","1012.10","221","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","204.49","58.3","","293.04","293.04","293.04","11","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","185.90","53","","983.89","983.89","983.89","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","203.44","58","","677.18","677.18","677.18","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","219.23","62.5","","46.58","46.58","46.58","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","256.05","73","","747.15","747.15","747.15","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.91","44.45","","1141.67","481.21","1141.67","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.91","44.45","","76.54","76.54","76.54","1 through 10","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.76","263.07","WELLPOINT [1015]","HB CH WELLPOINT","273.28","77.91","","273.64","94.28","1367.51","138","155.91","273.28","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.76","263.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.00","59.3","","720.78","230.14","2010.94","427","175.38","275.17","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.76","263.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","208.00","59.3","","344.45","344.45","344.45","1 through 10","175.38","275.17","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.76","263.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","275.17","78.45","","1120.13","1120.13","1120.13","1 through 10","175.38","275.17","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.76","263.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","275.17","78.45","","456.17","105.33","1284.66","242","175.38","275.17","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","AETNA [1001]","HB CH AETNA HMO / PPO","444.58","58.3","","464.71","67.87","1012.10","221","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","444.58","58.3","","293.04","293.04","293.04","11","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.16","53","","983.89","983.89","983.89","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","442.29","58","","677.18","677.18","677.18","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","476.61","62.5","","46.58","46.58","46.58","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","556.68","73","","747.15","747.15","747.15","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.96","44.45","","1141.67","481.21","1141.67","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.96","44.45","","76.54","76.54","76.54","1 through 10","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","WELLPOINT [1015]","HB CH WELLPOINT","594.12","77.91","","273.64","94.28","1367.51","138","338.96","594.12","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","452.20","59.3","","720.78","230.14","2010.94","427","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","452.20","59.3","","344.45","344.45","344.45","1 through 10","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","598.24","78.45","","1120.13","1120.13","1120.13","1 through 10","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","598.24","78.45","","456.17","105.33","1284.66","242","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","AETNA [1001]","HB CH AETNA HMO / PPO","464.64","58.3","","464.71","67.87","1012.10","221","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","464.64","58.3","","293.04","293.04","293.04","11","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","422.40","53","","983.89","983.89","983.89","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","462.25","58","","677.18","677.18","677.18","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","498.11","62.5","","46.58","46.58","46.58","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","581.80","73","","747.15","747.15","747.15","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.26","44.45","","1141.67","481.21","1141.67","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.26","44.45","","76.54","76.54","76.54","1 through 10","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","WELLPOINT [1015]","HB CH WELLPOINT","620.93","77.91","","273.64","94.28","1367.51","138","354.26","620.93","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","472.61","59.3","","720.78","230.14","2010.94","427","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","472.61","59.3","","344.45","344.45","344.45","1 through 10","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","625.23","78.45","","1120.13","1120.13","1120.13","1 through 10","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","625.23","78.45","","456.17","105.33","1284.66","242","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","AETNA [1001]","HB CH AETNA HMO / PPO","485.35","58.3","","464.71","67.87","1012.10","221","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","485.35","58.3","","293.04","293.04","293.04","11","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","441.23","53","","983.89","983.89","983.89","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","482.85","58","","677.18","677.18","677.18","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","520.31","62.5","","46.58","46.58","46.58","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","607.73","73","","747.15","747.15","747.15","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.05","44.45","","1141.67","481.21","1141.67","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.05","44.45","","76.54","76.54","76.54","1 through 10","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","WELLPOINT [1015]","HB CH WELLPOINT","648.60","77.91","","273.64","94.28","1367.51","138","370.05","648.6","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","493.67","59.3","","720.78","230.14","2010.94","427","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","493.67","59.3","","344.45","344.45","344.45","1 through 10","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","653.10","78.45","","1120.13","1120.13","1120.13","1 through 10","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","653.10","78.45","","456.17","105.33","1284.66","242","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","AETNA [1001]","HB CH AETNA HMO / PPO","526.76","58.3","","464.71","67.87","1012.10","221","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.76","58.3","","293.04","293.04","293.04","11","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.88","53","","983.89","983.89","983.89","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","524.05","58","","677.18","677.18","677.18","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","564.71","62.5","","46.58","46.58","46.58","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","659.58","73","","747.15","747.15","747.15","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.62","44.45","","1141.67","481.21","1141.67","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.62","44.45","","76.54","76.54","76.54","1 through 10","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","WELLPOINT [1015]","HB CH WELLPOINT","703.95","77.91","","273.64","94.28","1367.51","138","401.62","703.95","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.80","59.3","","720.78","230.14","2010.94","427","451.77","708.83","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","535.80","59.3","","344.45","344.45","344.45","1 through 10","451.77","708.83","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","708.83","78.45","","1120.13","1120.13","1120.13","1 through 10","451.77","708.83","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","708.83","78.45","","456.17","105.33","1284.66","242","451.77","708.83","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","464.71","67.87","1012.10","221","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","293.04","293.04","293.04","11","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","983.89","983.89","983.89","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1569.48","58","","677.18","677.18","677.18","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1691.25","62.5","","46.58","46.58","46.58","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","747.15","747.15","747.15","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.82","44.45","","1141.67","481.21","1141.67","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.82","44.45","","76.54","76.54","76.54","1 through 10","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","273.64","94.28","1367.51","138","1202.82","2108.24","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","720.78","230.14","2010.94","427","1353","2122.86","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1604.66","59.3","","344.45","344.45","344.45","1 through 10","1353","2122.86","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","1120.13","1120.13","1120.13","1 through 10","1353","2122.86","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","456.17","105.33","1284.66","242","1353","2122.86","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","AETNA [1001]","HB CH AETNA HMO / PPO","2108.51","58.3","","464.71","67.87","1012.10","221","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2108.51","58.3","","293.04","293.04","293.04","11","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1916.82","53","","983.89","983.89","983.89","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2097.66","58","","677.18","677.18","677.18","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2260.41","62.5","","46.58","46.58","46.58","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2640.15","73","","747.15","747.15","747.15","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1607.60","44.45","","1141.67","481.21","1141.67","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1607.60","44.45","","76.54","76.54","76.54","1 through 10","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.65","2712.49","WELLPOINT [1015]","HB CH WELLPOINT","2817.73","77.91","","273.64","94.28","1367.51","138","1607.6","2817.73","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.65","2712.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","2144.67","59.3","","720.78","230.14","2010.94","427","1808.33","2837.26","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.65","2712.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2144.67","59.3","","344.45","344.45","344.45","1 through 10","1808.33","2837.26","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.65","2712.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2837.26","78.45","","1120.13","1120.13","1120.13","1 through 10","1808.33","2837.26","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.65","2712.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2837.26","78.45","","456.17","105.33","1284.66","242","1808.33","2837.26","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","AETNA [1001]","HB CH AETNA HMO / PPO","2206.89","58.3","","464.71","67.87","1012.10","221","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2206.89","58.3","","293.04","293.04","293.04","11","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2006.26","53","","983.89","983.89","983.89","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2195.53","58","","677.18","677.18","677.18","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2365.88","62.5","","46.58","46.58","46.58","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2763.34","73","","747.15","747.15","747.15","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.61","44.45","","1141.67","481.21","1141.67","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.61","44.45","","76.54","76.54","76.54","1 through 10","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.40","2839.05","WELLPOINT [1015]","HB CH WELLPOINT","2949.21","77.91","","273.64","94.28","1367.51","138","1682.61","2949.21","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.40","2839.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","2244.74","59.3","","720.78","230.14","2010.94","427","1892.7","2969.65","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.40","2839.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2244.74","59.3","","344.45","344.45","344.45","1 through 10","1892.7","2969.65","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.40","2839.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2969.65","78.45","","1120.13","1120.13","1120.13","1 through 10","1892.7","2969.65","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.40","2839.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2969.65","78.45","","456.17","105.33","1284.66","242","1892.7","2969.65","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","AETNA [1001]","HB CH AETNA HMO / PPO","2252.54","58.3","","464.71","67.87","1012.10","221","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2252.54","58.3","","293.04","293.04","293.04","11","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2047.76","53","","983.89","983.89","983.89","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2240.95","58","","677.18","677.18","677.18","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2414.81","62.5","","46.58","46.58","46.58","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2820.50","73","","747.15","747.15","747.15","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1717.41","44.45","","1141.67","481.21","1141.67","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1717.41","44.45","","76.54","76.54","76.54","1 through 10","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.70","2897.77","WELLPOINT [1015]","HB CH WELLPOINT","3010.21","77.91","","273.64","94.28","1367.51","138","1717.41","3010.21","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.70","2897.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2291.17","59.3","","720.78","230.14","2010.94","427","1931.85","3031.07","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.70","2897.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2291.17","59.3","","344.45","344.45","344.45","1 through 10","1931.85","3031.07","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.70","2897.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3031.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1931.85","3031.07","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED LEFT","SUP-ITM-10095164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.70","2897.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3031.07","78.45","","456.17","105.33","1284.66","242","1931.85","3031.07","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","AETNA [1001]","HB CH AETNA HMO / PPO","2450.87","58.3","","464.71","67.87","1012.10","221","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2450.87","58.3","","293.04","293.04","293.04","11","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2228.07","53","","983.89","983.89","983.89","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2438.26","58","","677.18","677.18","677.18","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2627.44","62.5","","46.58","46.58","46.58","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3068.85","73","","747.15","747.15","747.15","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1868.63","44.45","","1141.67","481.21","1141.67","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1868.63","44.45","","76.54","76.54","76.54","1 through 10","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.90","3152.92","WELLPOINT [1015]","HB CH WELLPOINT","3275.26","77.91","","273.64","94.28","1367.51","138","1868.63","3275.26","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.90","3152.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","2492.91","59.3","","720.78","230.14","2010.94","427","2101.95","3297.96","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.90","3152.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2492.91","59.3","","344.45","344.45","344.45","1 through 10","2101.95","3297.96","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.90","3152.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3297.96","78.45","","1120.13","1120.13","1120.13","1 through 10","2101.95","3297.96","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.90","3152.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3297.96","78.45","","456.17","105.33","1284.66","242","2101.95","3297.96","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","AETNA [1001]","HB CH AETNA HMO / PPO","2609.86","58.3","","464.71","67.87","1012.10","221","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2609.86","58.3","","293.04","293.04","293.04","11","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2372.60","53","","983.89","983.89","983.89","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2596.43","58","","677.18","677.18","677.18","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2797.88","62.5","","46.58","46.58","46.58","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3267.92","73","","747.15","747.15","747.15","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.85","44.45","","1141.67","481.21","1141.67","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.85","44.45","","76.54","76.54","76.54","1 through 10","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4476.60","3357.45","WELLPOINT [1015]","HB CH WELLPOINT","3487.72","77.91","","273.64","94.28","1367.51","138","1989.85","3487.72","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4476.60","3357.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","2654.62","59.3","","720.78","230.14","2010.94","427","2238.3","3511.89","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4476.60","3357.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2654.62","59.3","","344.45","344.45","344.45","1 through 10","2238.3","3511.89","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4476.60","3357.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3511.89","78.45","","1120.13","1120.13","1120.13","1 through 10","2238.3","3511.89","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4476.60","3357.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3511.89","78.45","","456.17","105.33","1284.66","242","2238.3","3511.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","AETNA [1001]","HB CH AETNA HMO / PPO","871.68","58.3","","464.71","67.87","1012.10","221","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","871.68","58.3","","293.04","293.04","293.04","11","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","792.44","53","","983.89","983.89","983.89","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","867.20","58","","677.18","677.18","677.18","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","934.48","62.5","","46.58","46.58","46.58","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1091.47","73","","747.15","747.15","747.15","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","664.60","44.45","","1141.67","481.21","1141.67","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","664.60","44.45","","76.54","76.54","76.54","1 through 10","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","WELLPOINT [1015]","HB CH WELLPOINT","1164.89","77.91","","273.64","94.28","1367.51","138","664.6","1164.89","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","886.64","59.3","","720.78","230.14","2010.94","427","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","886.64","59.3","","344.45","344.45","344.45","1 through 10","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1172.96","78.45","","1120.13","1120.13","1120.13","1 through 10","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1172.96","78.45","","456.17","105.33","1284.66","242","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","AETNA [1001]","HB CH AETNA HMO / PPO","609.60","58.3","","464.71","67.87","1012.10","221","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","609.60","58.3","","293.04","293.04","293.04","11","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.18","53","","983.89","983.89","983.89","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","606.46","58","","677.18","677.18","677.18","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","653.51","62.5","","46.58","46.58","46.58","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","763.30","73","","747.15","747.15","747.15","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.78","44.45","","1141.67","481.21","1141.67","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.78","44.45","","76.54","76.54","76.54","1 through 10","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","WELLPOINT [1015]","HB CH WELLPOINT","814.64","77.91","","273.64","94.28","1367.51","138","464.78","814.64","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.05","59.3","","720.78","230.14","2010.94","427","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","620.05","59.3","","344.45","344.45","344.45","1 through 10","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","820.29","78.45","","1120.13","1120.13","1120.13","1 through 10","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","820.29","78.45","","456.17","105.33","1284.66","242","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","AETNA [1001]","HB CH AETNA HMO / PPO","1007.58","58.3","","464.71","67.87","1012.10","221","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1007.58","58.3","","293.04","293.04","293.04","11","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","915.98","53","","983.89","983.89","983.89","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1002.40","58","","677.18","677.18","677.18","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1080.17","62.5","","46.58","46.58","46.58","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1261.64","73","","747.15","747.15","747.15","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","768.22","44.45","","1141.67","481.21","1141.67","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","768.22","44.45","","76.54","76.54","76.54","1 through 10","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","WELLPOINT [1015]","HB CH WELLPOINT","1346.50","77.91","","273.64","94.28","1367.51","138","768.22","1346.5","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1024.86","59.3","","720.78","230.14","2010.94","427","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1024.86","59.3","","344.45","344.45","344.45","1 through 10","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1355.83","78.45","","1120.13","1120.13","1120.13","1 through 10","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1355.83","78.45","","456.17","105.33","1284.66","242","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","AETNA [1001]","HB CH AETNA HMO / PPO","681.43","58.3","","464.71","67.87","1012.10","221","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","681.43","58.3","","293.04","293.04","293.04","11","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","619.48","53","","983.89","983.89","983.89","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","677.92","58","","677.18","677.18","677.18","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","730.52","62.5","","46.58","46.58","46.58","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","853.25","73","","747.15","747.15","747.15","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.54","44.45","","1141.67","481.21","1141.67","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.54","44.45","","76.54","76.54","76.54","1 through 10","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","WELLPOINT [1015]","HB CH WELLPOINT","910.64","77.91","","273.64","94.28","1367.51","138","519.54","910.64","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.12","59.3","","720.78","230.14","2010.94","427","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","693.12","59.3","","344.45","344.45","344.45","1 through 10","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","916.95","78.45","","1120.13","1120.13","1120.13","1 through 10","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","916.95","78.45","","456.17","105.33","1284.66","242","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","AETNA [1001]","HB CH AETNA HMO / PPO","603.13","58.3","","464.71","67.87","1012.10","221","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","603.13","58.3","","293.04","293.04","293.04","11","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","548.30","53","","983.89","983.89","983.89","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","600.02","58","","677.18","677.18","677.18","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","646.58","62.5","","46.58","46.58","46.58","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","755.20","73","","747.15","747.15","747.15","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.84","44.45","","1141.67","481.21","1141.67","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.84","44.45","","76.54","76.54","76.54","1 through 10","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","WELLPOINT [1015]","HB CH WELLPOINT","805.99","77.91","","273.64","94.28","1367.51","138","459.84","805.99","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","613.47","59.3","","720.78","230.14","2010.94","427","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","613.47","59.3","","344.45","344.45","344.45","1 through 10","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","811.58","78.45","","1120.13","1120.13","1120.13","1 through 10","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","811.58","78.45","","456.17","105.33","1284.66","242","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","AETNA [1001]","HB CH AETNA HMO / PPO","674.96","58.3","","464.71","67.87","1012.10","221","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","674.96","58.3","","293.04","293.04","293.04","11","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","613.60","53","","983.89","983.89","983.89","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","671.48","58","","677.18","677.18","677.18","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","723.58","62.5","","46.58","46.58","46.58","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","845.14","73","","747.15","747.15","747.15","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","514.61","44.45","","1141.67","481.21","1141.67","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","514.61","44.45","","76.54","76.54","76.54","1 through 10","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","WELLPOINT [1015]","HB CH WELLPOINT","901.99","77.91","","273.64","94.28","1367.51","138","514.61","901.99","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","686.53","59.3","","720.78","230.14","2010.94","427","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","686.53","59.3","","344.45","344.45","344.45","1 through 10","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","908.24","78.45","","1120.13","1120.13","1120.13","1 through 10","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","908.24","78.45","","456.17","105.33","1284.66","242","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","AETNA [1001]","HB CH AETNA HMO / PPO","2063.70","58.3","","464.71","67.87","1012.10","221","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2063.70","58.3","","293.04","293.04","293.04","11","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1876.09","53","","983.89","983.89","983.89","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2053.08","58","","677.18","677.18","677.18","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2212.37","62.5","","46.58","46.58","46.58","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2584.05","73","","747.15","747.15","747.15","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1573.44","44.45","","1141.67","481.21","1141.67","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1573.44","44.45","","76.54","76.54","76.54","1 through 10","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","WELLPOINT [1015]","HB CH WELLPOINT","2757.85","77.91","","273.64","94.28","1367.51","138","1573.44","2757.85","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","2099.10","59.3","","720.78","230.14","2010.94","427","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2099.10","59.3","","344.45","344.45","344.45","1 through 10","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2776.97","78.45","","1120.13","1120.13","1120.13","1 through 10","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2776.97","78.45","","456.17","105.33","1284.66","242","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","AETNA [1001]","HB CH AETNA HMO / PPO","737.73","58.3","","464.71","67.87","1012.10","221","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","737.73","58.3","","293.04","293.04","293.04","11","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","670.66","53","","983.89","983.89","983.89","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","733.93","58","","677.18","677.18","677.18","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","790.88","62.5","","46.58","46.58","46.58","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","923.74","73","","747.15","747.15","747.15","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.47","44.45","","1141.67","481.21","1141.67","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.47","44.45","","76.54","76.54","76.54","1 through 10","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","WELLPOINT [1015]","HB CH WELLPOINT","985.87","77.91","","273.64","94.28","1367.51","138","562.47","985.87","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","750.38","59.3","","720.78","230.14","2010.94","427","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","750.38","59.3","","344.45","344.45","344.45","1 through 10","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","992.71","78.45","","1120.13","1120.13","1120.13","1 through 10","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","992.71","78.45","","456.17","105.33","1284.66","242","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","AETNA [1001]","HB CH AETNA HMO / PPO","630.95","58.3","","464.71","67.87","1012.10","221","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","630.95","58.3","","293.04","293.04","293.04","11","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","573.59","53","","983.89","983.89","983.89","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","627.71","58","","677.18","677.18","677.18","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","676.41","62.5","","46.58","46.58","46.58","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.04","73","","747.15","747.15","747.15","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.06","44.45","","1141.67","481.21","1141.67","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.06","44.45","","76.54","76.54","76.54","1 through 10","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","WELLPOINT [1015]","HB CH WELLPOINT","843.18","77.91","","273.64","94.28","1367.51","138","481.06","843.18","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","641.77","59.3","","720.78","230.14","2010.94","427","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","641.77","59.3","","344.45","344.45","344.45","1 through 10","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","849.03","78.45","","1120.13","1120.13","1120.13","1 through 10","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.03","78.45","","456.17","105.33","1284.66","242","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","AETNA [1001]","HB CH AETNA HMO / PPO","732.55","58.3","","464.71","67.87","1012.10","221","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","732.55","58.3","","293.04","293.04","293.04","11","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","665.96","53","","983.89","983.89","983.89","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","728.78","58","","677.18","677.18","677.18","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","785.33","62.5","","46.58","46.58","46.58","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","917.26","73","","747.15","747.15","747.15","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","558.52","44.45","","1141.67","481.21","1141.67","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","558.52","44.45","","76.54","76.54","76.54","1 through 10","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","WELLPOINT [1015]","HB CH WELLPOINT","978.95","77.91","","273.64","94.28","1367.51","138","558.52","978.95","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","745.12","59.3","","720.78","230.14","2010.94","427","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","745.12","59.3","","344.45","344.45","344.45","1 through 10","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","985.74","78.45","","1120.13","1120.13","1120.13","1 through 10","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","985.74","78.45","","456.17","105.33","1284.66","242","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","AETNA [1001]","HB CH AETNA HMO / PPO","793.38","58.3","","464.71","67.87","1012.10","221","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","793.38","58.3","","293.04","293.04","293.04","11","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","721.26","53","","983.89","983.89","983.89","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","789.30","58","","677.18","677.18","677.18","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","850.54","62.5","","46.58","46.58","46.58","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","993.43","73","","747.15","747.15","747.15","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.90","44.45","","1141.67","481.21","1141.67","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.90","44.45","","76.54","76.54","76.54","1 through 10","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","WELLPOINT [1015]","HB CH WELLPOINT","1060.25","77.91","","273.64","94.28","1367.51","138","604.9","1060.25","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","806.99","59.3","","720.78","230.14","2010.94","427","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","806.99","59.3","","344.45","344.45","344.45","1 through 10","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1067.59","78.45","","1120.13","1120.13","1120.13","1 through 10","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1067.59","78.45","","456.17","105.33","1284.66","242","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","AETNA [1001]","HB CH AETNA HMO / PPO","685.31","58.3","","464.71","67.87","1012.10","221","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","685.31","58.3","","293.04","293.04","293.04","11","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","623.01","53","","983.89","983.89","983.89","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","681.78","58","","677.18","677.18","677.18","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","734.68","62.5","","46.58","46.58","46.58","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","858.11","73","","747.15","747.15","747.15","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.51","44.45","","1141.67","481.21","1141.67","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.51","44.45","","76.54","76.54","76.54","1 through 10","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","WELLPOINT [1015]","HB CH WELLPOINT","915.82","77.91","","273.64","94.28","1367.51","138","522.51","915.82","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","697.07","59.3","","720.78","230.14","2010.94","427","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","697.07","59.3","","344.45","344.45","344.45","1 through 10","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","922.17","78.45","","1120.13","1120.13","1120.13","1 through 10","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","922.17","78.45","","456.17","105.33","1284.66","242","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","AETNA [1001]","HB CH AETNA HMO / PPO","789.50","58.3","","464.71","67.87","1012.10","221","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","789.50","58.3","","293.04","293.04","293.04","11","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","717.73","53","","983.89","983.89","983.89","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","785.44","58","","677.18","677.18","677.18","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","846.38","62.5","","46.58","46.58","46.58","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","988.57","73","","747.15","747.15","747.15","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","601.94","44.45","","1141.67","481.21","1141.67","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","601.94","44.45","","76.54","76.54","76.54","1 through 10","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.20","1015.65","WELLPOINT [1015]","HB CH WELLPOINT","1055.06","77.91","","273.64","94.28","1367.51","138","601.94","1055.06","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.20","1015.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","803.04","59.3","","720.78","230.14","2010.94","427","677.1","1062.37","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.20","1015.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","803.04","59.3","","344.45","344.45","344.45","1 through 10","677.1","1062.37","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.20","1015.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1062.37","78.45","","1120.13","1120.13","1120.13","1 through 10","677.1","1062.37","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.20","1015.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1062.37","78.45","","456.17","105.33","1284.66","242","677.1","1062.37","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","464.71","67.87","1012.10","221","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","293.04","293.04","293.04","11","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","983.89","983.89","983.89","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","840.16","58","","677.18","677.18","677.18","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","905.34","62.5","","46.58","46.58","46.58","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","747.15","747.15","747.15","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","1141.67","481.21","1141.67","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","76.54","76.54","76.54","1 through 10","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","273.64","94.28","1367.51","138","643.88","1128.57","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","720.78","230.14","2010.94","427","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","858.99","59.3","","344.45","344.45","344.45","1 through 10","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","1120.13","1120.13","1120.13","1 through 10","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","456.17","105.33","1284.66","242","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","AETNA [1001]","HB CH AETNA HMO / PPO","2101.88","58.3","","464.71","67.87","1012.10","221","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2101.88","58.3","","293.04","293.04","293.04","11","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1910.80","53","","983.89","983.89","983.89","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2091.06","58","","677.18","677.18","677.18","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2253.30","62.5","","46.58","46.58","46.58","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2631.85","73","","747.15","747.15","747.15","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1602.55","44.45","","1141.67","481.21","1141.67","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1602.55","44.45","","76.54","76.54","76.54","1 through 10","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3605.28","2703.96","WELLPOINT [1015]","HB CH WELLPOINT","2808.87","77.91","","273.64","94.28","1367.51","138","1602.55","2808.87","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3605.28","2703.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","2137.93","59.3","","720.78","230.14","2010.94","427","1802.64","2828.34","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3605.28","2703.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2137.93","59.3","","344.45","344.45","344.45","1 through 10","1802.64","2828.34","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3605.28","2703.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2828.34","78.45","","1120.13","1120.13","1120.13","1 through 10","1802.64","2828.34","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3605.28","2703.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2828.34","78.45","","456.17","105.33","1284.66","242","1802.64","2828.34","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","AETNA [1001]","HB CH AETNA HMO / PPO","848.39","58.3","","464.71","67.87","1012.10","221","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","848.39","58.3","","293.04","293.04","293.04","11","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.26","53","","983.89","983.89","983.89","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","844.02","58","","677.18","677.18","677.18","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","909.51","62.5","","46.58","46.58","46.58","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.30","73","","747.15","747.15","747.15","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.84","44.45","","1141.67","481.21","1141.67","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.84","44.45","","76.54","76.54","76.54","1 through 10","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","WELLPOINT [1015]","HB CH WELLPOINT","1133.75","77.91","","273.64","94.28","1367.51","138","646.84","1133.75","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.94","59.3","","720.78","230.14","2010.94","427","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","862.94","59.3","","344.45","344.45","344.45","1 through 10","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1141.61","78.45","","1120.13","1120.13","1120.13","1 through 10","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.61","78.45","","456.17","105.33","1284.66","242","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","AETNA [1001]","HB CH AETNA HMO / PPO","896.28","58.3","","464.71","67.87","1012.10","221","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","896.28","58.3","","293.04","293.04","293.04","11","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","814.80","53","","983.89","983.89","983.89","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","891.66","58","","677.18","677.18","677.18","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","960.84","62.5","","46.58","46.58","46.58","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1122.27","73","","747.15","747.15","747.15","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.35","44.45","","1141.67","481.21","1141.67","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.35","44.45","","76.54","76.54","76.54","1 through 10","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","WELLPOINT [1015]","HB CH WELLPOINT","1197.75","77.91","","273.64","94.28","1367.51","138","683.35","1197.75","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","911.65","59.3","","720.78","230.14","2010.94","427","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","911.65","59.3","","344.45","344.45","344.45","1 through 10","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1206.05","78.45","","1120.13","1120.13","1120.13","1 through 10","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1206.05","78.45","","456.17","105.33","1284.66","242","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","AETNA [1001]","HB CH AETNA HMO / PPO","2179.53","58.3","","464.71","67.87","1012.10","221","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2179.53","58.3","","293.04","293.04","293.04","11","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1981.39","53","","983.89","983.89","983.89","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2168.32","58","","677.18","677.18","677.18","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2336.55","62.5","","46.58","46.58","46.58","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2729.09","73","","747.15","747.15","747.15","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.75","44.45","","1141.67","481.21","1141.67","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.75","44.45","","76.54","76.54","76.54","1 through 10","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","3738.48","2803.86","WELLPOINT [1015]","HB CH WELLPOINT","2912.65","77.91","","273.64","94.28","1367.51","138","1661.75","2912.65","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3738.48","2803.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.92","59.3","","720.78","230.14","2010.94","427","1869.24","2932.84","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3738.48","2803.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.92","59.3","","344.45","344.45","344.45","1 through 10","1869.24","2932.84","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3738.48","2803.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.84","78.45","","1120.13","1120.13","1120.13","1 through 10","1869.24","2932.84","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3738.48","2803.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.84","78.45","","456.17","105.33","1284.66","242","1869.24","2932.84","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","AETNA [1001]","HB CH AETNA HMO / PPO","889.80","58.3","","464.71","67.87","1012.10","221","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","889.80","58.3","","293.04","293.04","293.04","11","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","808.91","53","","983.89","983.89","983.89","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","885.23","58","","677.18","677.18","677.18","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","953.91","62.5","","46.58","46.58","46.58","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1114.16","73","","747.15","747.15","747.15","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","678.42","44.45","","1141.67","481.21","1141.67","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","678.42","44.45","","76.54","76.54","76.54","1 through 10","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","WELLPOINT [1015]","HB CH WELLPOINT","1189.10","77.91","","273.64","94.28","1367.51","138","678.42","1189.1","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","905.07","59.3","","720.78","230.14","2010.94","427","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","905.07","59.3","","344.45","344.45","344.45","1 through 10","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1197.34","78.45","","1120.13","1120.13","1120.13","1 through 10","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1197.34","78.45","","456.17","105.33","1284.66","242","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","AETNA [1001]","HB CH AETNA HMO / PPO","2223.54","58.3","","464.71","67.87","1012.10","221","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2223.54","58.3","","293.04","293.04","293.04","11","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2021.40","53","","983.89","983.89","983.89","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2212.10","58","","677.18","677.18","677.18","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2383.73","62.5","","46.58","46.58","46.58","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2784.19","73","","747.15","747.15","747.15","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1695.31","44.45","","1141.67","481.21","1141.67","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1695.31","44.45","","76.54","76.54","76.54","1 through 10","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.96","2860.47","WELLPOINT [1015]","HB CH WELLPOINT","2971.46","77.91","","273.64","94.28","1367.51","138","1695.31","2971.46","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.96","2860.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2261.68","59.3","","720.78","230.14","2010.94","427","1906.98","2992.05","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.96","2860.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2261.68","59.3","","344.45","344.45","344.45","1 through 10","1906.98","2992.05","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.96","2860.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2992.05","78.45","","1120.13","1120.13","1120.13","1 through 10","1906.98","2992.05","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.96","2860.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2992.05","78.45","","456.17","105.33","1284.66","242","1906.98","2992.05","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","AETNA [1001]","HB CH AETNA HMO / PPO","1107.24","58.3","","464.71","67.87","1012.10","221","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1107.24","58.3","","293.04","293.04","293.04","11","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1006.58","53","","983.89","983.89","983.89","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1101.54","58","","677.18","677.18","677.18","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1187.01","62.5","","46.58","46.58","46.58","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1386.42","73","","747.15","747.15","747.15","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","844.20","44.45","","1141.67","481.21","1141.67","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","844.20","44.45","","76.54","76.54","76.54","1 through 10","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.21","1424.41","WELLPOINT [1015]","HB CH WELLPOINT","1479.67","77.91","","273.64","94.28","1367.51","138","844.2","1479.67","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.21","1424.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1126.23","59.3","","720.78","230.14","2010.94","427","949.61","1489.93","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.21","1424.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1126.23","59.3","","344.45","344.45","344.45","1 through 10","949.61","1489.93","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.21","1424.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1489.93","78.45","","1120.13","1120.13","1120.13","1 through 10","949.61","1489.93","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.21","1424.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1489.93","78.45","","456.17","105.33","1284.66","242","949.61","1489.93","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","AETNA [1001]","HB CH AETNA HMO / PPO","1039.29","58.3","","464.71","67.87","1012.10","221","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1039.29","58.3","","293.04","293.04","293.04","11","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","944.81","53","","983.89","983.89","983.89","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1033.94","58","","677.18","677.18","677.18","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1114.16","62.5","","46.58","46.58","46.58","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1301.34","73","","747.15","747.15","747.15","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.39","44.45","","1141.67","481.21","1141.67","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.39","44.45","","76.54","76.54","76.54","1 through 10","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","WELLPOINT [1015]","HB CH WELLPOINT","1388.87","77.91","","273.64","94.28","1367.51","138","792.39","1388.87","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1057.12","59.3","","720.78","230.14","2010.94","427","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1057.12","59.3","","344.45","344.45","344.45","1 through 10","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1398.50","78.45","","1120.13","1120.13","1120.13","1 through 10","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1398.50","78.45","","456.17","105.33","1284.66","242","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","AETNA [1001]","HB CH AETNA HMO / PPO","1269.67","58.3","","464.71","67.87","1012.10","221","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1269.67","58.3","","293.04","293.04","293.04","11","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1154.24","53","","983.89","983.89","983.89","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1263.14","58","","677.18","677.18","677.18","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1361.14","62.5","","46.58","46.58","46.58","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1589.81","73","","747.15","747.15","747.15","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","968.04","44.45","","1141.67","481.21","1141.67","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","968.04","44.45","","76.54","76.54","76.54","1 through 10","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2177.82","1633.36","WELLPOINT [1015]","HB CH WELLPOINT","1696.74","77.91","","273.64","94.28","1367.51","138","968.04","1696.74","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2177.82","1633.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","1291.45","59.3","","720.78","230.14","2010.94","427","1088.91","1708.5","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2177.82","1633.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1291.45","59.3","","344.45","344.45","344.45","1 through 10","1088.91","1708.5","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2177.82","1633.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1708.50","78.45","","1120.13","1120.13","1120.13","1 through 10","1088.91","1708.5","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2177.82","1633.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1708.50","78.45","","456.17","105.33","1284.66","242","1088.91","1708.5","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","AETNA [1001]","HB CH AETNA HMO / PPO","1383.56","58.3","","464.71","67.87","1012.10","221","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1383.56","58.3","","293.04","293.04","293.04","11","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1257.79","53","","983.89","983.89","983.89","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1376.44","58","","677.18","677.18","677.18","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1483.24","62.5","","46.58","46.58","46.58","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1732.42","73","","747.15","747.15","747.15","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1054.88","44.45","","1141.67","481.21","1141.67","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1054.88","44.45","","76.54","76.54","76.54","1 through 10","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2373.18","1779.88","WELLPOINT [1015]","HB CH WELLPOINT","1848.94","77.91","","273.64","94.28","1367.51","138","1054.88","1848.94","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2373.18","1779.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","1407.30","59.3","","720.78","230.14","2010.94","427","1186.59","1861.76","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2373.18","1779.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1407.30","59.3","","344.45","344.45","344.45","1 through 10","1186.59","1861.76","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2373.18","1779.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1861.76","78.45","","1120.13","1120.13","1120.13","1 through 10","1186.59","1861.76","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2373.18","1779.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1861.76","78.45","","456.17","105.33","1284.66","242","1186.59","1861.76","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","AETNA [1001]","HB CH AETNA HMO / PPO","434.87","58.3","","464.71","67.87","1012.10","221","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","434.87","58.3","","293.04","293.04","293.04","11","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","395.34","53","","983.89","983.89","983.89","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","432.63","58","","677.18","677.18","677.18","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","466.20","62.5","","46.58","46.58","46.58","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","544.52","73","","747.15","747.15","747.15","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.56","44.45","","1141.67","481.21","1141.67","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.56","44.45","","76.54","76.54","76.54","1 through 10","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","WELLPOINT [1015]","HB CH WELLPOINT","581.15","77.91","","273.64","94.28","1367.51","138","331.56","581.15","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","442.33","59.3","","720.78","230.14","2010.94","427","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","442.33","59.3","","344.45","344.45","344.45","1 through 10","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","585.17","78.45","","1120.13","1120.13","1120.13","1 through 10","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","585.17","78.45","","456.17","105.33","1284.66","242","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","AETNA [1001]","HB CH AETNA HMO / PPO","761.67","58.3","","464.71","67.87","1012.10","221","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","761.67","58.3","","293.04","293.04","293.04","11","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","692.43","53","","983.89","983.89","983.89","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","757.75","58","","677.18","677.18","677.18","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","816.54","62.5","","46.58","46.58","46.58","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","953.72","73","","747.15","747.15","747.15","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.73","44.45","","1141.67","481.21","1141.67","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.73","44.45","","76.54","76.54","76.54","1 through 10","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","WELLPOINT [1015]","HB CH WELLPOINT","1017.87","77.91","","273.64","94.28","1367.51","138","580.73","1017.87","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","774.74","59.3","","720.78","230.14","2010.94","427","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","774.74","59.3","","344.45","344.45","344.45","1 through 10","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1024.93","78.45","","1120.13","1120.13","1120.13","1 through 10","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1024.93","78.45","","456.17","105.33","1284.66","242","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","AETNA [1001]","HB CH AETNA HMO / PPO","497.64","58.3","","464.71","67.87","1012.10","221","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","497.64","58.3","","293.04","293.04","293.04","11","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","452.40","53","","983.89","983.89","983.89","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.08","58","","677.18","677.18","677.18","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","533.49","62.5","","46.58","46.58","46.58","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","623.12","73","","747.15","747.15","747.15","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.42","44.45","","1141.67","481.21","1141.67","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.42","44.45","","76.54","76.54","76.54","1 through 10","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","WELLPOINT [1015]","HB CH WELLPOINT","665.03","77.91","","273.64","94.28","1367.51","138","379.42","665.03","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","506.18","59.3","","720.78","230.14","2010.94","427","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","506.18","59.3","","344.45","344.45","344.45","1 through 10","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","669.64","78.45","","1120.13","1120.13","1120.13","1 through 10","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","669.64","78.45","","456.17","105.33","1284.66","242","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","AETNA [1001]","HB CH AETNA HMO / PPO","465.29","58.3","","464.71","67.87","1012.10","221","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","465.29","58.3","","293.04","293.04","293.04","11","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","422.99","53","","983.89","983.89","983.89","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","462.89","58","","677.18","677.18","677.18","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","498.81","62.5","","46.58","46.58","46.58","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","582.61","73","","747.15","747.15","747.15","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.75","44.45","","1141.67","481.21","1141.67","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.75","44.45","","76.54","76.54","76.54","1 through 10","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","WELLPOINT [1015]","HB CH WELLPOINT","621.79","77.91","","273.64","94.28","1367.51","138","354.75","621.79","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","473.27","59.3","","720.78","230.14","2010.94","427","399.05","626.1","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","473.27","59.3","","344.45","344.45","344.45","1 through 10","399.05","626.1","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","626.10","78.45","","1120.13","1120.13","1120.13","1 through 10","399.05","626.1","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","626.10","78.45","","456.17","105.33","1284.66","242","399.05","626.1","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","AETNA [1001]","HB CH AETNA HMO / PPO","546.18","58.3","","464.71","67.87","1012.10","221","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","546.18","58.3","","293.04","293.04","293.04","11","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","496.53","53","","983.89","983.89","983.89","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","543.37","58","","677.18","677.18","677.18","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","585.53","62.5","","46.58","46.58","46.58","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","683.89","73","","747.15","747.15","747.15","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.43","44.45","","1141.67","481.21","1141.67","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.43","44.45","","76.54","76.54","76.54","1 through 10","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","WELLPOINT [1015]","HB CH WELLPOINT","729.89","77.91","","273.64","94.28","1367.51","138","416.43","729.89","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","555.55","59.3","","720.78","230.14","2010.94","427","468.42","734.95","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","555.55","59.3","","344.45","344.45","344.45","1 through 10","468.42","734.95","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","734.95","78.45","","1120.13","1120.13","1120.13","1 through 10","468.42","734.95","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","734.95","78.45","","456.17","105.33","1284.66","242","468.42","734.95","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","AETNA [1001]","HB CH AETNA HMO / PPO","517.06","58.3","","464.71","67.87","1012.10","221","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","517.06","58.3","","293.04","293.04","293.04","11","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","470.05","53","","983.89","983.89","983.89","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","514.40","58","","677.18","677.18","677.18","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","554.31","62.5","","46.58","46.58","46.58","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","647.43","73","","747.15","747.15","747.15","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.22","44.45","","1141.67","481.21","1141.67","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.22","44.45","","76.54","76.54","76.54","1 through 10","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","886.89","665.17","WELLPOINT [1015]","HB CH WELLPOINT","690.98","77.91","","273.64","94.28","1367.51","138","394.22","690.98","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","525.93","59.3","","720.78","230.14","2010.94","427","443.45","695.77","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","525.93","59.3","","344.45","344.45","344.45","1 through 10","443.45","695.77","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","695.77","78.45","","1120.13","1120.13","1120.13","1 through 10","443.45","695.77","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","886.89","665.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","695.77","78.45","","456.17","105.33","1284.66","242","443.45","695.77","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","AETNA [1001]","HB CH AETNA HMO / PPO","988.81","58.3","","464.71","67.87","1012.10","221","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","988.81","58.3","","293.04","293.04","293.04","11","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","898.92","53","","983.89","983.89","983.89","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","983.73","58","","677.18","677.18","677.18","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1060.05","62.5","","46.58","46.58","46.58","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1238.14","73","","747.15","747.15","747.15","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.91","44.45","","1141.67","481.21","1141.67","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.91","44.45","","76.54","76.54","76.54","1 through 10","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","WELLPOINT [1015]","HB CH WELLPOINT","1321.42","77.91","","273.64","94.28","1367.51","138","753.91","1321.42","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.78","59.3","","720.78","230.14","2010.94","427","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1005.78","59.3","","344.45","344.45","344.45","1 through 10","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1330.57","78.45","","1120.13","1120.13","1120.13","1 through 10","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1330.57","78.45","","456.17","105.33","1284.66","242","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","2190.90","412.50","9264.59","16","493.4","864.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","643.80","58","","1903.20","1903.20","3826.66","1 through 10","493.4","864.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","693.75","62.5","","2186.25","2186.25","2186.25","32","493.4","864.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","5556.60","5556.60","5556.60","1 through 10","493.4","864.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","WELLPOINT [1015]","HB CH WELLPOINT","864.80","77.91","","1955.15","885.83","3150.40","26","493.4","864.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","831.03","253.22","2394.88","18","555","870.8","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","2481.69","1563.74","8149.28","1 through 10","555","870.8","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","AETNA [1001]","HB CH AETNA HMO / PPO","967.46","58.3","","464.71","67.87","1012.10","221","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","967.46","58.3","","293.04","293.04","293.04","11","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","879.51","53","","983.89","983.89","983.89","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","962.48","58","","677.18","677.18","677.18","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1037.16","62.5","","46.58","46.58","46.58","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1211.40","73","","747.15","747.15","747.15","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.63","44.45","","1141.67","481.21","1141.67","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.63","44.45","","76.54","76.54","76.54","1 through 10","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","WELLPOINT [1015]","HB CH WELLPOINT","1292.88","77.91","","273.64","94.28","1367.51","138","737.63","1292.88","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","984.05","59.3","","720.78","230.14","2010.94","427","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","984.05","59.3","","344.45","344.45","344.45","1 through 10","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1301.84","78.45","","1120.13","1120.13","1120.13","1 through 10","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1301.84","78.45","","456.17","105.33","1284.66","242","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","AETNA [1001]","HB CH AETNA HMO / PPO","216.14","58.3","","464.71","67.87","1012.10","221","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","216.14","58.3","","293.04","293.04","293.04","11","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","196.49","53","","983.89","983.89","983.89","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","215.03","58","","677.18","677.18","677.18","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","231.71","62.5","","46.58","46.58","46.58","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","270.64","73","","747.15","747.15","747.15","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.79","44.45","","1141.67","481.21","1141.67","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.79","44.45","","76.54","76.54","76.54","1 through 10","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","WELLPOINT [1015]","HB CH WELLPOINT","288.84","77.91","","273.64","94.28","1367.51","138","164.79","288.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","219.85","59.3","","720.78","230.14","2010.94","427","185.37","290.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","219.85","59.3","","344.45","344.45","344.45","1 through 10","185.37","290.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","290.85","78.45","","1120.13","1120.13","1120.13","1 through 10","185.37","290.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","290.85","78.45","","456.17","105.33","1284.66","242","185.37","290.85","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","AETNA [1001]","HB CH AETNA HMO / PPO","739.02","58.3","","464.71","67.87","1012.10","221","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","739.02","58.3","","293.04","293.04","293.04","11","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","671.84","53","","983.89","983.89","983.89","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","735.22","58","","677.18","677.18","677.18","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","792.26","62.5","","46.58","46.58","46.58","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","925.36","73","","747.15","747.15","747.15","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.46","44.45","","1141.67","481.21","1141.67","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.46","44.45","","76.54","76.54","76.54","1 through 10","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","WELLPOINT [1015]","HB CH WELLPOINT","987.60","77.91","","273.64","94.28","1367.51","138","563.46","987.6","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","751.70","59.3","","720.78","230.14","2010.94","427","633.81","994.45","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","751.70","59.3","","344.45","344.45","344.45","1 through 10","633.81","994.45","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","994.45","78.45","","1120.13","1120.13","1120.13","1 through 10","633.81","994.45","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","994.45","78.45","","456.17","105.33","1284.66","242","633.81","994.45","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","AETNA [1001]","HB CH AETNA HMO / PPO","1696.53","58.3","","464.71","67.87","1012.10","221","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1696.53","58.3","","293.04","293.04","293.04","11","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1542.30","53","","983.89","983.89","983.89","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1687.80","58","","677.18","677.18","677.18","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1818.75","62.5","","46.58","46.58","46.58","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2124.30","73","","747.15","747.15","747.15","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1293.50","44.45","","1141.67","481.21","1141.67","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1293.50","44.45","","76.54","76.54","76.54","1 through 10","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","WELLPOINT [1015]","HB CH WELLPOINT","2267.18","77.91","","273.64","94.28","1367.51","138","1293.5","2267.18","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1725.63","59.3","","720.78","230.14","2010.94","427","1455","2282.9","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1725.63","59.3","","344.45","344.45","344.45","1 through 10","1455","2282.9","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2282.90","78.45","","1120.13","1120.13","1120.13","1 through 10","1455","2282.9","percent of total billed charges",""
"BONE PLATE 7 HOLE RADIAL VOLAR PEG FIXED ANGLE RIGHT","SUP-ITM-10100701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2282.90","78.45","","456.17","105.33","1284.66","242","1455","2282.9","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","AETNA [1001]","HB CH AETNA HMO / PPO","320.66","58.3","","464.71","67.87","1012.10","221","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","320.66","58.3","","293.04","293.04","293.04","11","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","291.51","53","","983.89","983.89","983.89","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","319.01","58","","677.18","677.18","677.18","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","343.76","62.5","","46.58","46.58","46.58","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","401.51","73","","747.15","747.15","747.15","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.48","44.45","","1141.67","481.21","1141.67","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.48","44.45","","76.54","76.54","76.54","1 through 10","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","WELLPOINT [1015]","HB CH WELLPOINT","428.52","77.91","","273.64","94.28","1367.51","138","244.48","428.52","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","326.16","59.3","","720.78","230.14","2010.94","427","275.01","431.49","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","326.16","59.3","","344.45","344.45","344.45","1 through 10","275.01","431.49","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","431.49","78.45","","1120.13","1120.13","1120.13","1 through 10","275.01","431.49","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","431.49","78.45","","456.17","105.33","1284.66","242","275.01","431.49","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","AETNA [1001]","HB CH AETNA HMO / PPO","2132.12","58.3","","464.71","67.87","1012.10","221","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2132.12","58.3","","293.04","293.04","293.04","11","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1938.29","53","","983.89","983.89","983.89","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2121.15","58","","677.18","677.18","677.18","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2285.73","62.5","","46.58","46.58","46.58","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.73","73","","747.15","747.15","747.15","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.61","44.45","","1141.67","481.21","1141.67","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.61","44.45","","76.54","76.54","76.54","1 through 10","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","WELLPOINT [1015]","HB CH WELLPOINT","2849.29","77.91","","273.64","94.28","1367.51","138","1625.61","2849.29","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.70","59.3","","720.78","230.14","2010.94","427","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2168.70","59.3","","344.45","344.45","344.45","1 through 10","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2869.04","78.45","","1120.13","1120.13","1120.13","1 through 10","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 74MM 3 HOLE VARIAX TITANIUM SUPERIOR LATERAL LEFT","SUP-ITM-10114800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2869.04","78.45","","456.17","105.33","1284.66","242","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","AETNA [1001]","HB CH AETNA HMO / PPO","2120.66","58.3","","464.71","67.87","1012.10","221","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2120.66","58.3","","293.04","293.04","293.04","11","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1927.88","53","","983.89","983.89","983.89","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2109.75","58","","677.18","677.18","677.18","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2273.44","62.5","","46.58","46.58","46.58","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2655.38","73","","747.15","747.15","747.15","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1616.87","44.45","","1141.67","481.21","1141.67","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1616.87","44.45","","76.54","76.54","76.54","1 through 10","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","both","","","3637.50","2728.12","WELLPOINT [1015]","HB CH WELLPOINT","2833.98","77.91","","273.64","94.28","1367.51","138","1616.87","2833.98","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3637.50","2728.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.04","59.3","","720.78","230.14","2010.94","427","1818.75","2853.62","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3637.50","2728.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2157.04","59.3","","344.45","344.45","344.45","1 through 10","1818.75","2853.62","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3637.50","2728.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2853.62","78.45","","1120.13","1120.13","1120.13","1 through 10","1818.75","2853.62","percent of total billed charges",""
"BONE PLATE 8 HOLE BRIDGE WRIST FIXATION SYSTEM SS","SUP-ITM-10208442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3637.50","2728.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2853.62","78.45","","456.17","105.33","1284.66","242","1818.75","2853.62","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","AETNA [1001]","HB CH AETNA HMO / PPO","520.29","58.3","","464.71","67.87","1012.10","221","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","520.29","58.3","","293.04","293.04","293.04","11","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","472.99","53","","983.89","983.89","983.89","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","517.62","58","","677.18","677.18","677.18","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","557.78","62.5","","46.58","46.58","46.58","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","651.48","73","","747.15","747.15","747.15","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.69","44.45","","1141.67","481.21","1141.67","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.69","44.45","","76.54","76.54","76.54","1 through 10","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","WELLPOINT [1015]","HB CH WELLPOINT","695.30","77.91","","273.64","94.28","1367.51","138","396.69","695.3","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","529.22","59.3","","720.78","230.14","2010.94","427","446.22","700.12","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","529.22","59.3","","344.45","344.45","344.45","1 through 10","446.22","700.12","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","700.12","78.45","","1120.13","1120.13","1120.13","1 through 10","446.22","700.12","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","700.12","78.45","","456.17","105.33","1284.66","242","446.22","700.12","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","AETNA [1001]","HB CH AETNA HMO / PPO","851.97","58.3","","464.71","67.87","1012.10","221","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","851.97","58.3","","293.04","293.04","293.04","11","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","774.52","53","","983.89","983.89","983.89","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","847.59","58","","677.18","677.18","677.18","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","913.35","62.5","","46.58","46.58","46.58","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1066.79","73","","747.15","747.15","747.15","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","649.57","44.45","","1141.67","481.21","1141.67","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","649.57","44.45","","76.54","76.54","76.54","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","WELLPOINT [1015]","HB CH WELLPOINT","1138.55","77.91","","273.64","94.28","1367.51","138","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","866.59","59.3","","720.78","230.14","2010.94","427","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","866.59","59.3","","344.45","344.45","344.45","1 through 10","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1146.44","78.45","","1120.13","1120.13","1120.13","1 through 10","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1146.44","78.45","","456.17","105.33","1284.66","242","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","AETNA [1001]","HB CH AETNA HMO / PPO","1218.98","58.3","","464.71","67.87","1012.10","221","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1218.98","58.3","","293.04","293.04","293.04","11","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1108.17","53","","983.89","983.89","983.89","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1212.71","58","","677.18","677.18","677.18","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1306.80","62.5","","46.58","46.58","46.58","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1526.34","73","","747.15","747.15","747.15","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","929.40","44.45","","1141.67","481.21","1141.67","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","929.40","44.45","","76.54","76.54","76.54","1 through 10","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.88","1568.16","WELLPOINT [1015]","HB CH WELLPOINT","1629.00","77.91","","273.64","94.28","1367.51","138","929.4","1629","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.88","1568.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","1239.89","59.3","","720.78","230.14","2010.94","427","1045.44","1640.3","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.88","1568.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1239.89","59.3","","344.45","344.45","344.45","1 through 10","1045.44","1640.3","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.88","1568.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1640.30","78.45","","1120.13","1120.13","1120.13","1 through 10","1045.44","1640.3","percent of total billed charges",""
"BONE PLATE 84MM 6 HOLE VARIAX SS FIBULA STRAIGHT","SUP-ITM-10142415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.88","1568.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1640.30","78.45","","456.17","105.33","1284.66","242","1045.44","1640.3","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","AETNA [1001]","HB CH AETNA HMO / PPO","392.81","58.3","","464.71","67.87","1012.10","221","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","392.81","58.3","","293.04","293.04","293.04","11","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.10","53","","983.89","983.89","983.89","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","390.79","58","","677.18","677.18","677.18","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.11","62.5","","46.58","46.58","46.58","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","491.85","73","","747.15","747.15","747.15","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.49","44.45","","1141.67","481.21","1141.67","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.49","44.45","","76.54","76.54","76.54","1 through 10","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","WELLPOINT [1015]","HB CH WELLPOINT","524.93","77.91","","273.64","94.28","1367.51","138","299.49","524.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","399.55","59.3","","720.78","230.14","2010.94","427","336.89","528.57","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","399.55","59.3","","344.45","344.45","344.45","1 through 10","336.89","528.57","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","528.57","78.45","","1120.13","1120.13","1120.13","1 through 10","336.89","528.57","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","528.57","78.45","","456.17","105.33","1284.66","242","336.89","528.57","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","AETNA [1001]","HB CH AETNA HMO / PPO","646.43","58.3","","464.71","67.87","1012.10","221","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","646.43","58.3","","293.04","293.04","293.04","11","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","587.66","53","","983.89","983.89","983.89","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","643.10","58","","677.18","677.18","677.18","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","693.00","62.5","","46.58","46.58","46.58","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","809.42","73","","747.15","747.15","747.15","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.86","44.45","","1141.67","481.21","1141.67","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.86","44.45","","76.54","76.54","76.54","1 through 10","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.80","831.60","WELLPOINT [1015]","HB CH WELLPOINT","863.87","77.91","","273.64","94.28","1367.51","138","492.86","863.87","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.80","831.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","657.52","59.3","","720.78","230.14","2010.94","427","554.4","869.85","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.80","831.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","657.52","59.3","","344.45","344.45","344.45","1 through 10","554.4","869.85","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.80","831.60","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","869.85","78.45","","1120.13","1120.13","1120.13","1 through 10","554.4","869.85","percent of total billed charges",""
"BONE PLATE 86X2.7 3.5MM 4 HOLE LCP STAINLESS RIGHT","SUP-ITM-10091118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.80","831.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","869.85","78.45","","456.17","105.33","1284.66","242","554.4","869.85","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","AETNA [1001]","HB CH AETNA HMO / PPO","2398.33","58.3","","464.71","67.87","1012.10","221","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2398.33","58.3","","293.04","293.04","293.04","11","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.30","53","","983.89","983.89","983.89","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2385.99","58","","677.18","677.18","677.18","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2571.11","62.5","","46.58","46.58","46.58","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.06","73","","747.15","747.15","747.15","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.58","44.45","","1141.67","481.21","1141.67","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.58","44.45","","76.54","76.54","76.54","1 through 10","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","WELLPOINT [1015]","HB CH WELLPOINT","3205.05","77.91","","273.64","94.28","1367.51","138","1828.58","3205.05","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","2439.47","59.3","","720.78","230.14","2010.94","427","2056.89","3227.26","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2439.47","59.3","","344.45","344.45","344.45","1 through 10","2056.89","3227.26","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3227.26","78.45","","1120.13","1120.13","1120.13","1 through 10","2056.89","3227.26","percent of total billed charges",""
"BONE PLATE 88MM 7 HOLE VARIAX TITANIUM SUPERIOR MIDSHAFT LEFT","SUP-ITM-10114774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3227.26","78.45","","456.17","105.33","1284.66","242","2056.89","3227.26","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","AETNA [1001]","HB CH AETNA HMO / PPO","231.03","58.3","","464.71","67.87","1012.10","221","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","231.03","58.3","","293.04","293.04","293.04","11","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","210.02","53","","983.89","983.89","983.89","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","229.84","58","","677.18","677.18","677.18","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","247.67","62.5","","46.58","46.58","46.58","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","289.28","73","","747.15","747.15","747.15","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.14","44.45","","1141.67","481.21","1141.67","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.14","44.45","","76.54","76.54","76.54","1 through 10","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","WELLPOINT [1015]","HB CH WELLPOINT","308.73","77.91","","273.64","94.28","1367.51","138","176.14","308.73","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","234.99","59.3","","720.78","230.14","2010.94","427","198.14","310.87","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","234.99","59.3","","344.45","344.45","344.45","1 through 10","198.14","310.87","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","310.87","78.45","","1120.13","1120.13","1120.13","1 through 10","198.14","310.87","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","310.87","78.45","","456.17","105.33","1284.66","242","198.14","310.87","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","AETNA [1001]","HB CH AETNA HMO / PPO","851.97","58.3","","464.71","67.87","1012.10","221","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","851.97","58.3","","293.04","293.04","293.04","11","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","774.52","53","","983.89","983.89","983.89","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","847.59","58","","677.18","677.18","677.18","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","913.35","62.5","","46.58","46.58","46.58","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1066.79","73","","747.15","747.15","747.15","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","649.57","44.45","","1141.67","481.21","1141.67","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","649.57","44.45","","76.54","76.54","76.54","1 through 10","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1461.36","1096.02","WELLPOINT [1015]","HB CH WELLPOINT","1138.55","77.91","","273.64","94.28","1367.51","138","649.57","1138.55","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","866.59","59.3","","720.78","230.14","2010.94","427","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","866.59","59.3","","344.45","344.45","344.45","1 through 10","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1146.44","78.45","","1120.13","1120.13","1120.13","1 through 10","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1461.36","1096.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1146.44","78.45","","456.17","105.33","1284.66","242","730.68","1146.44","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","AETNA [1001]","HB CH AETNA HMO / PPO","2185.52","58.3","","464.71","67.87","1012.10","221","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2185.52","58.3","","293.04","293.04","293.04","11","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1986.83","53","","983.89","983.89","983.89","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2174.27","58","","677.18","677.18","677.18","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2342.96","62.5","","46.58","46.58","46.58","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2736.58","73","","747.15","747.15","747.15","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.31","44.45","","1141.67","481.21","1141.67","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.31","44.45","","76.54","76.54","76.54","1 through 10","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","both","","","3748.74","2811.55","WELLPOINT [1015]","HB CH WELLPOINT","2920.64","77.91","","273.64","94.28","1367.51","138","1666.31","2920.64","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3748.74","2811.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.00","59.3","","720.78","230.14","2010.94","427","1874.37","2940.89","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3748.74","2811.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.00","59.3","","344.45","344.45","344.45","1 through 10","1874.37","2940.89","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3748.74","2811.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2940.89","78.45","","1120.13","1120.13","1120.13","1 through 10","1874.37","2940.89","percent of total billed charges",""
"BONE PLATE 95MM 5 HOLE LCP STAINLESS META VOLAR EXTRA ARTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10023169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3748.74","2811.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2940.89","78.45","","456.17","105.33","1284.66","242","1874.37","2940.89","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","AETNA [1001]","HB CH AETNA HMO / PPO","253.03","58.3","","464.71","67.87","1012.10","221","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.03","58.3","","293.04","293.04","293.04","11","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.03","53","","983.89","983.89","983.89","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","251.73","58","","677.18","677.18","677.18","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","271.26","62.5","","46.58","46.58","46.58","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","316.83","73","","747.15","747.15","747.15","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","192.92","44.45","","1141.67","481.21","1141.67","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","192.92","44.45","","76.54","76.54","76.54","1 through 10","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","434.01","325.51","WELLPOINT [1015]","HB CH WELLPOINT","338.14","77.91","","273.64","94.28","1367.51","138","192.92","338.14","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","434.01","325.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.37","59.3","","720.78","230.14","2010.94","427","217.01","340.48","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","434.01","325.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","257.37","59.3","","344.45","344.45","344.45","1 through 10","217.01","340.48","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","434.01","325.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","340.48","78.45","","1120.13","1120.13","1120.13","1 through 10","217.01","340.48","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","434.01","325.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","340.48","78.45","","456.17","105.33","1284.66","242","217.01","340.48","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","AETNA [1001]","HB CH AETNA HMO / PPO","144.50","58.3","","464.71","67.87","1012.10","221","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.50","58.3","","293.04","293.04","293.04","11","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.37","53","","983.89","983.89","983.89","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","143.76","58","","677.18","677.18","677.18","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","154.91","62.5","","46.58","46.58","46.58","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","180.94","73","","747.15","747.15","747.15","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.17","44.45","","1141.67","481.21","1141.67","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.17","44.45","","76.54","76.54","76.54","1 through 10","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","WELLPOINT [1015]","HB CH WELLPOINT","193.11","77.91","","273.64","94.28","1367.51","138","110.17","193.11","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.98","59.3","","720.78","230.14","2010.94","427","123.93","194.45","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","146.98","59.3","","344.45","344.45","344.45","1 through 10","123.93","194.45","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","194.45","78.45","","1120.13","1120.13","1120.13","1 through 10","123.93","194.45","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.45","78.45","","456.17","105.33","1284.66","242","123.93","194.45","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","AETNA [1001]","HB CH AETNA HMO / PPO","336.87","58.3","","464.71","67.87","1012.10","221","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","336.87","58.3","","293.04","293.04","293.04","11","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","306.25","53","","983.89","983.89","983.89","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","335.14","58","","677.18","677.18","677.18","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","361.14","62.5","","46.58","46.58","46.58","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","421.82","73","","747.15","747.15","747.15","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.85","44.45","","1141.67","481.21","1141.67","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.85","44.45","","76.54","76.54","76.54","1 through 10","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","WELLPOINT [1015]","HB CH WELLPOINT","450.19","77.91","","273.64","94.28","1367.51","138","256.85","450.19","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.65","59.3","","720.78","230.14","2010.94","427","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","342.65","59.3","","344.45","344.45","344.45","1 through 10","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","453.31","78.45","","1120.13","1120.13","1120.13","1 through 10","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.31","78.45","","456.17","105.33","1284.66","242","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","AETNA [1001]","HB CH AETNA HMO / PPO","409.63","58.3","","464.71","67.87","1012.10","221","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.63","58.3","","293.04","293.04","293.04","11","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.39","53","","983.89","983.89","983.89","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","407.53","58","","677.18","677.18","677.18","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","439.14","62.5","","46.58","46.58","46.58","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","747.15","747.15","747.15","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","1141.67","481.21","1141.67","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","76.54","76.54","76.54","1 through 10","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","WELLPOINT [1015]","HB CH WELLPOINT","547.42","77.91","","273.64","94.28","1367.51","138","312.32","547.42","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.66","59.3","","720.78","230.14","2010.94","427","351.32","551.21","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","416.66","59.3","","344.45","344.45","344.45","1 through 10","351.32","551.21","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","1120.13","1120.13","1120.13","1 through 10","351.32","551.21","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","456.17","105.33","1284.66","242","351.32","551.21","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","464.71","67.87","1012.10","221","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","293.04","293.04","293.04","11","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","983.89","983.89","983.89","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1653.00","58","","677.18","677.18","677.18","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1781.25","62.5","","46.58","46.58","46.58","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","747.15","747.15","747.15","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","1141.67","481.21","1141.67","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","76.54","76.54","76.54","1 through 10","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","273.64","94.28","1367.51","138","1266.83","2220.44","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","720.78","230.14","2010.94","427","1425","2235.83","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1690.05","59.3","","344.45","344.45","344.45","1 through 10","1425","2235.83","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","1120.13","1120.13","1120.13","1 through 10","1425","2235.83","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","456.17","105.33","1284.66","242","1425","2235.83","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","AETNA [1001]","HB CH AETNA HMO / PPO","883.25","58.3","","464.71","67.87","1012.10","221","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","883.25","58.3","","293.04","293.04","293.04","11","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","802.95","53","","983.89","983.89","983.89","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","878.70","58","","677.18","677.18","677.18","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","946.88","62.5","","46.58","46.58","46.58","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1105.95","73","","747.15","747.15","747.15","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.42","44.45","","1141.67","481.21","1141.67","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.42","44.45","","76.54","76.54","76.54","1 through 10","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","WELLPOINT [1015]","HB CH WELLPOINT","1180.34","77.91","","273.64","94.28","1367.51","138","673.42","1180.34","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","898.40","59.3","","720.78","230.14","2010.94","427","757.5","1188.52","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","898.40","59.3","","344.45","344.45","344.45","1 through 10","757.5","1188.52","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1188.52","78.45","","1120.13","1120.13","1120.13","1 through 10","757.5","1188.52","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1188.52","78.45","","456.17","105.33","1284.66","242","757.5","1188.52","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","AETNA [1001]","HB CH AETNA HMO / PPO","1302.03","58.3","","464.71","67.87","1012.10","221","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1302.03","58.3","","293.04","293.04","293.04","11","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1183.66","53","","983.89","983.89","983.89","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1295.33","58","","677.18","677.18","677.18","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1395.83","62.5","","46.58","46.58","46.58","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1630.32","73","","747.15","747.15","747.15","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","992.71","44.45","","1141.67","481.21","1141.67","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","992.71","44.45","","76.54","76.54","76.54","1 through 10","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","WELLPOINT [1015]","HB CH WELLPOINT","1739.98","77.91","","273.64","94.28","1367.51","138","992.71","1739.98","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1324.36","59.3","","720.78","230.14","2010.94","427","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1324.36","59.3","","344.45","344.45","344.45","1 through 10","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1752.04","78.45","","1120.13","1120.13","1120.13","1 through 10","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1752.04","78.45","","456.17","105.33","1284.66","242","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","AETNA [1001]","HB CH AETNA HMO / PPO","2363.70","58.3","","464.71","67.87","1012.10","221","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.70","58.3","","293.04","293.04","293.04","11","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.82","53","","983.89","983.89","983.89","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2351.54","58","","677.18","677.18","677.18","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2533.99","62.5","","46.58","46.58","46.58","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","747.15","747.15","747.15","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","1141.67","481.21","1141.67","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","76.54","76.54","76.54","1 through 10","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","WELLPOINT [1015]","HB CH WELLPOINT","3158.77","77.91","","273.64","94.28","1367.51","138","1802.17","3158.77","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.25","59.3","","720.78","230.14","2010.94","427","2027.19","3180.66","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2404.25","59.3","","344.45","344.45","344.45","1 through 10","2027.19","3180.66","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","1120.13","1120.13","1120.13","1 through 10","2027.19","3180.66","percent of total billed charges",""
"BONE PLATE LT FUSION LATERAL ANKLE TT","SUP-ITM-10235026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","456.17","105.33","1284.66","242","2027.19","3180.66","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","AETNA [1001]","HB CH AETNA HMO / PPO","1154.34","58.3","","464.71","67.87","1012.10","221","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1154.34","58.3","","293.04","293.04","293.04","11","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1049.40","53","","983.89","983.89","983.89","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1148.40","58","","677.18","677.18","677.18","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1237.50","62.5","","46.58","46.58","46.58","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1445.40","73","","747.15","747.15","747.15","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","880.11","44.45","","1141.67","481.21","1141.67","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","880.11","44.45","","76.54","76.54","76.54","1 through 10","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","both","","","1980.00","1485.00","WELLPOINT [1015]","HB CH WELLPOINT","1542.62","77.91","","273.64","94.28","1367.51","138","880.11","1542.62","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1980.00","1485.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1174.14","59.3","","720.78","230.14","2010.94","427","990","1553.31","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1980.00","1485.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1174.14","59.3","","344.45","344.45","344.45","1 through 10","990","1553.31","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1980.00","1485.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1553.31","78.45","","1120.13","1120.13","1120.13","1 through 10","990","1553.31","percent of total billed charges",""
"BONE PLATE PEDIATRIC 2.7MM PEDIFRAG LOCKING COMPRESSION 6 HOLE","SUP-ITM-10167795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1980.00","1485.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1553.31","78.45","","456.17","105.33","1284.66","242","990","1553.31","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","AETNA [1001]","HB CH AETNA HMO / PPO","2099.97","58.3","","464.71","67.87","1012.10","221","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2099.97","58.3","","293.04","293.04","293.04","11","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1909.06","53","","983.89","983.89","983.89","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2089.16","58","","677.18","677.18","677.18","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2251.25","62.5","","46.58","46.58","46.58","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2629.46","73","","747.15","747.15","747.15","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1601.09","44.45","","1141.67","481.21","1141.67","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1601.09","44.45","","76.54","76.54","76.54","1 through 10","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3602.00","2701.50","WELLPOINT [1015]","HB CH WELLPOINT","2806.32","77.91","","273.64","94.28","1367.51","138","1601.09","2806.32","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3602.00","2701.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2135.99","59.3","","720.78","230.14","2010.94","427","1801","2825.77","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3602.00","2701.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2135.99","59.3","","344.45","344.45","344.45","1 through 10","1801","2825.77","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3602.00","2701.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2825.77","78.45","","1120.13","1120.13","1120.13","1 through 10","1801","2825.77","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC RT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3602.00","2701.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2825.77","78.45","","456.17","105.33","1284.66","242","1801","2825.77","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","AETNA [1001]","HB CH AETNA HMO / PPO","2480.08","58.3","","464.71","67.87","1012.10","221","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2480.08","58.3","","293.04","293.04","293.04","11","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2254.62","53","","983.89","983.89","983.89","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2467.32","58","","677.18","677.18","677.18","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2658.75","62.5","","46.58","46.58","46.58","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3105.42","73","","747.15","747.15","747.15","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1890.90","44.45","","1141.67","481.21","1141.67","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1890.90","44.45","","76.54","76.54","76.54","1 through 10","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","both","","","4254.00","3190.50","WELLPOINT [1015]","HB CH WELLPOINT","3314.29","77.91","","273.64","94.28","1367.51","138","1890.9","3314.29","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4254.00","3190.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2522.62","59.3","","720.78","230.14","2010.94","427","2127","3337.26","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4254.00","3190.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2522.62","59.3","","344.45","344.45","344.45","1 through 10","2127","3337.26","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4254.00","3190.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3337.26","78.45","","1120.13","1120.13","1120.13","1 through 10","2127","3337.26","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL RIGHT","SUP-ITM-10132166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4254.00","3190.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3337.26","78.45","","456.17","105.33","1284.66","242","2127","3337.26","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","AETNA [1001]","HB CH AETNA HMO / PPO","1978.56","58.3","","464.71","67.87","1012.10","221","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1978.56","58.3","","293.04","293.04","293.04","11","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1798.69","53","","983.89","983.89","983.89","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1968.38","58","","677.18","677.18","677.18","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2121.09","62.5","","46.58","46.58","46.58","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2477.44","73","","747.15","747.15","747.15","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1508.52","44.45","","1141.67","481.21","1141.67","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1508.52","44.45","","76.54","76.54","76.54","1 through 10","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","WELLPOINT [1015]","HB CH WELLPOINT","2644.07","77.91","","273.64","94.28","1367.51","138","1508.52","2644.07","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2012.49","59.3","","720.78","230.14","2010.94","427","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2012.49","59.3","","344.45","344.45","344.45","1 through 10","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2662.40","78.45","","1120.13","1120.13","1120.13","1 through 10","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2662.40","78.45","","456.17","105.33","1284.66","242","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","AETNA [1001]","HB CH AETNA HMO / PPO","2449.33","58.3","","464.71","67.87","1012.10","221","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2449.33","58.3","","293.04","293.04","293.04","11","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.66","53","","983.89","983.89","983.89","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.73","58","","677.18","677.18","677.18","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.78","62.5","","46.58","46.58","46.58","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.91","73","","747.15","747.15","747.15","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1867.46","44.45","","1141.67","481.21","1141.67","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1867.46","44.45","","76.54","76.54","76.54","1 through 10","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","WELLPOINT [1015]","HB CH WELLPOINT","3273.19","77.91","","273.64","94.28","1367.51","138","1867.46","3273.19","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2491.34","59.3","","720.78","230.14","2010.94","427","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2491.34","59.3","","344.45","344.45","344.45","1 through 10","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3295.88","78.45","","1120.13","1120.13","1120.13","1 through 10","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3295.88","78.45","","456.17","105.33","1284.66","242","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","AETNA [1001]","HB CH AETNA HMO / PPO","996.93","58.3","","464.71","67.87","1012.10","221","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","996.93","58.3","","293.04","293.04","293.04","11","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","906.30","53","","983.89","983.89","983.89","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","991.80","58","","677.18","677.18","677.18","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1068.75","62.5","","46.58","46.58","46.58","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1248.30","73","","747.15","747.15","747.15","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","760.10","44.45","","1141.67","481.21","1141.67","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","760.10","44.45","","76.54","76.54","76.54","1 through 10","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.00","1282.50","WELLPOINT [1015]","HB CH WELLPOINT","1332.26","77.91","","273.64","94.28","1367.51","138","760.1","1332.26","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.00","1282.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1014.03","59.3","","720.78","230.14","2010.94","427","855","1341.5","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.00","1282.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1014.03","59.3","","344.45","344.45","344.45","1 through 10","855","1341.5","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.00","1282.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1341.50","78.45","","1120.13","1120.13","1120.13","1 through 10","855","1341.5","percent of total billed charges",""
"BONE PLATE VOLAR SHEAR 6 HOLE RIGHT","SUP-ITM-10100632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.00","1282.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1341.50","78.45","","456.17","105.33","1284.66","242","855","1341.5","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","464.71","67.87","1012.10","221","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","293.04","293.04","293.04","11","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","983.89","983.89","983.89","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","182.70","58","","677.18","677.18","677.18","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","196.88","62.5","","46.58","46.58","46.58","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","747.15","747.15","747.15","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","1141.67","481.21","1141.67","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","76.54","76.54","76.54","1 through 10","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","273.64","94.28","1367.51","138","140.02","245.42","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","720.78","230.14","2010.94","427","157.5","247.12","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","186.80","59.3","","344.45","344.45","344.45","1 through 10","157.5","247.12","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","1120.13","1120.13","1120.13","1 through 10","157.5","247.12","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","456.17","105.33","1284.66","242","157.5","247.12","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","AETNA [1001]","HB CH AETNA HMO / PPO","276.34","58.3","","2190.90","412.50","9264.59","16","210.69","369.29","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","274.92","58","","1903.20","1903.20","3826.66","1 through 10","210.69","369.29","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","296.25","62.5","","2186.25","2186.25","2186.25","32","210.69","369.29","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","346.02","73","","5556.60","5556.60","5556.60","1 through 10","210.69","369.29","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","WELLPOINT [1015]","HB CH WELLPOINT","369.29","77.91","","1955.15","885.83","3150.40","26","210.69","369.29","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","474.00","355.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","281.08","59.3","","831.03","253.22","2394.88","18","237","371.85","percent of total billed charges",""
"BONE ROD 4.5X50MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148218","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","371.85","78.45","","2481.69","1563.74","8149.28","1 through 10","237","371.85","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","AETNA [1001]","HB CH AETNA HMO / PPO","205.40","58.3","","464.71","67.87","1012.10","221","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","205.40","58.3","","293.04","293.04","293.04","11","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.73","53","","983.89","983.89","983.89","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","204.35","58","","677.18","677.18","677.18","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","220.20","62.5","","46.58","46.58","46.58","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","257.19","73","","747.15","747.15","747.15","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.61","44.45","","1141.67","481.21","1141.67","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.61","44.45","","76.54","76.54","76.54","1 through 10","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","WELLPOINT [1015]","HB CH WELLPOINT","274.49","77.91","","273.64","94.28","1367.51","138","156.61","274.49","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.93","59.3","","720.78","230.14","2010.94","427","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","208.93","59.3","","344.45","344.45","344.45","1 through 10","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","276.40","78.45","","1120.13","1120.13","1120.13","1 through 10","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.40","78.45","","456.17","105.33","1284.66","242","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","AETNA [1001]","HB CH AETNA HMO / PPO","219.39","58.3","","464.71","67.87","1012.10","221","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","219.39","58.3","","293.04","293.04","293.04","11","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","199.45","53","","983.89","983.89","983.89","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","218.27","58","","677.18","677.18","677.18","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","235.20","62.5","","46.58","46.58","46.58","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","274.71","73","","747.15","747.15","747.15","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.27","44.45","","1141.67","481.21","1141.67","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.27","44.45","","76.54","76.54","76.54","1 through 10","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","WELLPOINT [1015]","HB CH WELLPOINT","293.19","77.91","","273.64","94.28","1367.51","138","167.27","293.19","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.16","59.3","","720.78","230.14","2010.94","427","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","223.16","59.3","","344.45","344.45","344.45","1 through 10","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","295.22","78.45","","1120.13","1120.13","1120.13","1 through 10","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.22","78.45","","456.17","105.33","1284.66","242","188.16","295.22","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","AETNA [1001]","HB CH AETNA HMO / PPO","762.32","58.3","","464.71","67.87","1012.10","221","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","762.32","58.3","","293.04","293.04","293.04","11","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","693.02","53","","983.89","983.89","983.89","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","758.40","58","","677.18","677.18","677.18","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","817.24","62.5","","46.58","46.58","46.58","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","954.53","73","","747.15","747.15","747.15","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.22","44.45","","1141.67","481.21","1141.67","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.22","44.45","","76.54","76.54","76.54","1 through 10","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.58","980.68","WELLPOINT [1015]","HB CH WELLPOINT","1018.74","77.91","","273.64","94.28","1367.51","138","581.22","1018.74","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.58","980.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","775.39","59.3","","720.78","230.14","2010.94","427","653.79","1025.8","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.58","980.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","775.39","59.3","","344.45","344.45","344.45","1 through 10","653.79","1025.8","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.58","980.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1025.80","78.45","","1120.13","1120.13","1120.13","1 through 10","653.79","1025.8","percent of total billed charges",""
"BONE SCREW CANNULATED 03.037.010","SUP-ITM-10164550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.58","980.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1025.80","78.45","","456.17","105.33","1284.66","242","653.79","1025.8","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","AETNA [1001]","HB CH AETNA HMO / PPO","831.04","58.3","","464.71","67.87","1012.10","221","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","831.04","58.3","","293.04","293.04","293.04","11","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.49","53","","983.89","983.89","983.89","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","826.76","58","","677.18","677.18","677.18","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","890.91","62.5","","46.58","46.58","46.58","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.58","73","","747.15","747.15","747.15","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.61","44.45","","1141.67","481.21","1141.67","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.61","44.45","","76.54","76.54","76.54","1 through 10","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.45","1069.09","WELLPOINT [1015]","HB CH WELLPOINT","1110.57","77.91","","273.64","94.28","1367.51","138","633.61","1110.57","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.45","1069.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.29","59.3","","720.78","230.14","2010.94","427","712.73","1118.27","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.45","1069.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","845.29","59.3","","344.45","344.45","344.45","1 through 10","712.73","1118.27","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.45","1069.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1118.27","78.45","","1120.13","1120.13","1120.13","1 through 10","712.73","1118.27","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.45","1069.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1118.27","78.45","","456.17","105.33","1284.66","242","712.73","1118.27","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","2190.90","412.50","9264.59","16","933.45","1636.11","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","1903.20","1903.20","3826.66","1 through 10","933.45","1636.11","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","2186.25","2186.25","2186.25","32","933.45","1636.11","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","5556.60","5556.60","5556.60","1 through 10","933.45","1636.11","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1955.15","885.83","3150.40","26","933.45","1636.11","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","831.03","253.22","2394.88","18","1050","1647.45","percent of total billed charges",""
"BONE SPACER 44X14 11MM 9 GRAFT STRUT CORNERSTONE PEEK SQUARE RING","SUP-ITM-10059210","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2481.69","1563.74","8149.28","1 through 10","1050","1647.45","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.49","84.49","84.49","1 through 10","13.11","145.35","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.32","87.32","87.32","1 through 10","13.8","120.03","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"BOX COMPONENT 62.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"Bpd And Other Chronic Respiratory Diseases Arising In Perinatal Period,MODERATE","132","DRG","","","","","","","","inpatient","","","33180.53","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13689.171","","Fee schedule rate ($17,431.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13689.171","17431.46","17431.46","1 through 10","6340.5","28761.65","case rate",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","464.71","67.87","1012.10","221","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","293.04","293.04","293.04","11","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","983.89","983.89","983.89","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.75","58","","677.18","677.18","677.18","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.94","62.5","","46.58","46.58","46.58","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","747.15","747.15","747.15","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","1141.67","481.21","1141.67","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","76.54","76.54","76.54","1 through 10","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","273.64","94.28","1367.51","138","1661.32","2911.89","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","720.78","230.14","2010.94","427","1868.75","2932.07","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.34","59.3","","344.45","344.45","344.45","1 through 10","1868.75","2932.07","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.75","2932.07","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","456.17","105.33","1284.66","242","1868.75","2932.07","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","AETNA [1001]","HB CH AETNA HMO / PPO","2604.55","58.3","","2190.90","412.50","9264.59","16","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2591.15","58","","1903.20","1903.20","3826.66","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2792.19","62.5","","2186.25","2186.25","2186.25","32","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3261.28","73","","5556.60","5556.60","5556.60","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","WELLPOINT [1015]","HB CH WELLPOINT","3480.63","77.91","","1955.15","885.83","3150.40","26","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2649.23","59.3","","831.03","253.22","2394.88","18","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3504.75","78.45","","2481.69","1563.74","8149.28","1 through 10","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","AETNA [1001]","HB CH AETNA HMO / PPO","2188.00","58.3","","2190.90","412.50","9264.59","16","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2176.74","58","","1903.20","1903.20","3826.66","1 through 10","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2345.63","62.5","","2186.25","2186.25","2186.25","32","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2739.69","73","","5556.60","5556.60","5556.60","1 through 10","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","WELLPOINT [1015]","HB CH WELLPOINT","2923.96","77.91","","1955.15","885.83","3150.40","26","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2225.53","59.3","","831.03","253.22","2394.88","18","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 275CC 6.2CM 10.7CMX9.3CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2944.23","78.45","","2481.69","1563.74","8149.28","1 through 10","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","AETNA [1001]","HB CH AETNA HMO / PPO","2604.55","58.3","","2190.90","412.50","9264.59","16","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2591.15","58","","1903.20","1903.20","3826.66","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2792.19","62.5","","2186.25","2186.25","2186.25","32","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3261.28","73","","5556.60","5556.60","5556.60","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","WELLPOINT [1015]","HB CH WELLPOINT","3480.63","77.91","","1955.15","885.83","3150.40","26","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2649.23","59.3","","831.03","253.22","2394.88","18","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3504.75","78.45","","2481.69","1563.74","8149.28","1 through 10","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","AETNA [1001]","HB CH AETNA HMO / PPO","2188.00","58.3","","2190.90","412.50","9264.59","16","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2176.74","58","","1903.20","1903.20","3826.66","1 through 10","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2345.63","62.5","","2186.25","2186.25","2186.25","32","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2739.69","73","","5556.60","5556.60","5556.60","1 through 10","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","WELLPOINT [1015]","HB CH WELLPOINT","2923.96","77.91","","1955.15","885.83","3150.40","26","1668.21","2923.96","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2225.53","59.3","","831.03","253.22","2394.88","18","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2944.23","78.45","","2481.69","1563.74","8149.28","1 through 10","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","AETNA [1001]","HB CH AETNA HMO / PPO","2604.55","58.3","","2190.90","412.50","9264.59","16","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2591.15","58","","1903.20","1903.20","3826.66","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2792.19","62.5","","2186.25","2186.25","2186.25","32","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3261.28","73","","5556.60","5556.60","5556.60","1 through 10","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","4467.50","3350.62","WELLPOINT [1015]","HB CH WELLPOINT","3480.63","77.91","","1955.15","885.83","3150.40","26","1985.8","3480.63","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2649.23","59.3","","831.03","253.22","2394.88","18","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4467.50","3350.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3504.75","78.45","","2481.69","1563.74","8149.28","1 through 10","2233.75","3504.75","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","AETNA [1001]","HB CH AETNA HMO / PPO","2072.57","58.3","","2190.90","412.50","9264.59","16","1580.2","2769.7","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2061.90","58","","1903.20","1903.20","3826.66","1 through 10","1580.2","2769.7","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2221.88","62.5","","2186.25","2186.25","2186.25","32","1580.2","2769.7","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2595.15","73","","5556.60","5556.60","5556.60","1 through 10","1580.2","2769.7","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","WELLPOINT [1015]","HB CH WELLPOINT","2769.70","77.91","","1955.15","885.83","3150.40","26","1580.2","2769.7","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2108.12","59.3","","831.03","253.22","2394.88","18","1777.5","2788.9","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","2481.69","1563.74","8149.28","1 through 10","1777.5","2788.9","percent of total billed charges",""
"BREAST IMPLANT 175CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD10CM P3.1CM","SUP-ITM-10016937","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","1770.74","1316.58","1770.74","15","1230.66","1809.07","percent of total billed charges",""
"BREAST IMPLANT 175CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD10CM P3.1CM","SUP-ITM-10016937","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","2459.68","2459.68","2488.41","1 through 10","1230.66","1809.07","percent of total billed charges",""
"BREAST IMPLANT 175CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD10CM P3.1CM","SUP-ITM-10016937","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1376.95","59.3","","1830.08","1830.08","1830.08","11","1032.13","1821.61","percent of total billed charges",""
"BREAST IMPLANT 175CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD10CM P3.1CM","SUP-ITM-10016937","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","2400.96","2400.96","2400.96","1 through 10","1032.13","1821.61","percent of total billed charges",""
"BREAST IMPLANT 200 TO 240CC 10.0X3.7CM SALINE SMOOTH ROUND MODERATE PLUS NOMINAL FILL","SUP-ITM-10020226","CDM","C1789","HCPCS","0278","RC","","","","both","","","1179.00","884.25","AETNA [1001]","HB CH AETNA HMO / PPO","687.36","58.3","","1770.74","1316.58","1770.74","15","624.87","918.56","percent of total billed charges",""
"BREAST IMPLANT 200 TO 240CC 10.0X3.7CM SALINE SMOOTH ROUND MODERATE PLUS NOMINAL FILL","SUP-ITM-10020226","CDM","C1789","HCPCS","0278","RC","","","","both","","","1179.00","884.25","WELLPOINT [1015]","HB CH WELLPOINT","918.56","77.91","","2459.68","2459.68","2488.41","1 through 10","624.87","918.56","percent of total billed charges",""
"BREAST IMPLANT 200 TO 240CC 10.0X3.7CM SALINE SMOOTH ROUND MODERATE PLUS NOMINAL FILL","SUP-ITM-10020226","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1179.00","884.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","699.15","59.3","","1830.08","1830.08","1830.08","11","524.07","924.93","percent of total billed charges",""
"BREAST IMPLANT 200 TO 240CC 10.0X3.7CM SALINE SMOOTH ROUND MODERATE PLUS NOMINAL FILL","SUP-ITM-10020226","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1179.00","884.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","924.93","78.45","","2400.96","2400.96","2400.96","1 through 10","524.07","924.93","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","AETNA [1001]","HB CH AETNA HMO / PPO","1322.24","58.3","","1770.74","1316.58","1770.74","15","1202.04","1767","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","WELLPOINT [1015]","HB CH WELLPOINT","1767.00","77.91","","2459.68","2459.68","2488.41","1 through 10","1202.04","1767","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1344.92","59.3","","1830.08","1830.08","1830.08","11","1008.13","1779.25","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.25","78.45","","2400.96","2400.96","2400.96","1 through 10","1008.13","1779.25","percent of total billed charges",""
"BREAST IMPLANT 355CC GEL SMOOTH ROUND MODERATE PLUS","SUP-ITM-10139963","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","1770.74","1316.58","1770.74","15","1033.5","1519.25","percent of total billed charges",""
"BREAST IMPLANT 355CC GEL SMOOTH ROUND MODERATE PLUS","SUP-ITM-10139963","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","2459.68","2459.68","2488.41","1 through 10","1033.5","1519.25","percent of total billed charges",""
"BREAST IMPLANT 355CC GEL SMOOTH ROUND MODERATE PLUS","SUP-ITM-10139963","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","1830.08","1830.08","1830.08","11","866.78","1529.78","percent of total billed charges",""
"BREAST IMPLANT 355CC GEL SMOOTH ROUND MODERATE PLUS","SUP-ITM-10139963","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","2400.96","2400.96","2400.96","1 through 10","866.78","1529.78","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","both","","","2859.00","2144.25","AETNA [1001]","HB CH AETNA HMO / PPO","1666.80","58.3","","1770.74","1316.58","1770.74","15","1515.27","2227.45","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","both","","","2859.00","2144.25","WELLPOINT [1015]","HB CH WELLPOINT","2227.45","77.91","","2459.68","2459.68","2488.41","1 through 10","1515.27","2227.45","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2859.00","2144.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1695.39","59.3","","1830.08","1830.08","1830.08","11","1270.83","2242.89","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2859.00","2144.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2242.89","78.45","","2400.96","2400.96","2400.96","1 through 10","1270.83","2242.89","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","AETNA [1001]","HB CH AETNA HMO / PPO","1820.71","58.3","","1770.74","1316.58","1770.74","15","1655.19","2433.13","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","WELLPOINT [1015]","HB CH WELLPOINT","2433.13","77.91","","2459.68","2459.68","2488.41","1 through 10","1655.19","2433.13","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1851.94","59.3","","1830.08","1830.08","1830.08","11","1388.17","2449.99","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2449.99","78.45","","2400.96","2400.96","2400.96","1 through 10","1388.17","2449.99","percent of total billed charges",""
"BREAST IMPLANT 420CC MEDIUM HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10139460","CDM","C1789","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","AETNA [1001]","HB CH AETNA HMO / PPO","1909.33","58.3","","1770.74","1316.58","1770.74","15","1735.75","2551.55","percent of total billed charges",""
"BREAST IMPLANT 420CC MEDIUM HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10139460","CDM","C1789","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","WELLPOINT [1015]","HB CH WELLPOINT","2551.55","77.91","","2459.68","2459.68","2488.41","1 through 10","1735.75","2551.55","percent of total billed charges",""
"BREAST IMPLANT 420CC MEDIUM HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10139460","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1942.08","59.3","","1830.08","1830.08","1830.08","11","1455.74","2569.24","percent of total billed charges",""
"BREAST IMPLANT 420CC MEDIUM HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10139460","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2569.24","78.45","","2400.96","2400.96","2400.96","1 through 10","1455.74","2569.24","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","1770.74","1316.58","1770.74","15","453.15","666.13","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","2459.68","2459.68","2488.41","1 through 10","453.15","666.13","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","1830.08","1830.08","1830.08","11","380.05","670.75","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","2400.96","2400.96","2400.96","1 through 10","380.05","670.75","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","AETNA [1001]","HB CH AETNA HMO / PPO","1322.24","58.3","","1770.74","1316.58","1770.74","15","1202.04","1767","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","WELLPOINT [1015]","HB CH WELLPOINT","1767.00","77.91","","2459.68","2459.68","2488.41","1 through 10","1202.04","1767","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1344.92","59.3","","1830.08","1830.08","1830.08","11","1008.13","1779.25","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.25","78.45","","2400.96","2400.96","2400.96","1 through 10","1008.13","1779.25","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","AETNA [1001]","HB CH AETNA HMO / PPO","1189.32","58.3","","1770.74","1316.58","1770.74","15","1081.2","1589.36","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","WELLPOINT [1015]","HB CH WELLPOINT","1589.36","77.91","","2459.68","2459.68","2488.41","1 through 10","1081.2","1589.36","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1209.72","59.3","","1830.08","1830.08","1830.08","11","906.78","1600.38","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1600.38","78.45","","2400.96","2400.96","2400.96","1 through 10","906.78","1600.38","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","1193.00","894.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,919). Procedure 2, Per diem ($1,459.50). Procedures 3 - 9999, Per diem ($729.50).","2919.00","2919.00","2919.00","1 through 10","511.8","4509.37","per diem",""
"Bronchiolitis And Rsv Pneumonia,EXTREME","138","DRG","","","","","","","","inpatient","","","13401.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16974.90","","Fee schedule rate ($16,974.90). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($1,964.10) multiplied by length of stay and the outlier percent (100%).","3985.12","3985.12","3985.12","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,EXTREME","138","DRG","","","","","","","","inpatient","","","13401.23","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9386.0226","","Fee schedule rate ($44,020.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9386.0226","44020.30","44020.30","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16974.90","","Standard inlier is a Case rate ($16,974.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,859, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,409.51) for the length of stay and the standard reimbursement.","2299.93","1964.09","16974.89","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9386.0226","","Fee schedule rate ($24,996.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9386.0226","24996.18","24996.18","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9855.2757","","Fee schedule rate ($26,245.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9855.2757","25234.08","25234.08","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","27495.53","","Fee schedule rate ($27,495.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27495.52","27495.52","27495.52","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","MASSHEALTH [3001]","HB NWH MEDICAID","6763.95","","Case rate ($7,287.09). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,717.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9132.28","9132.28","9132.28","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11134.89","","Fee schedule rate ($11,134.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9464.73","9464.73","9464.73","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23733.48","","Fee schedule rate ($23,733.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23042.43","23042.43","23042.43","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","6763.95","","Case rate ($7,287.09). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,717.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9132.28","9132.28","9132.28","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","13100.84","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6763.95","","Case rate ($7,287.09). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,717.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9132.28","9132.28","9132.28","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6964.71","","Standard inlier is a Case rate ($6,964.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($988.67) for the length of stay and the standard reimbursement.","6648.22","6648.22","6648.22","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","7481.49","","Standard inlier is a Case rate ($7,481.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,061.97) for the length of stay and the standard reimbursement.","7141.42","7141.42","7481.48","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9386.0226","","Fee schedule rate ($9,386.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9386.0226","9386.02","9386.02","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","MASSHEALTH [3001]","HB NWH MEDICAID","3190.63","","Case rate ($3,437.40). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,867.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4307.80","4307.80","4307.80","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","3190.63","","Case rate ($3,437.40). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,867.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4307.80","4307.80","4307.80","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MINOR","138","DRG","","","","","","","","inpatient","","","9669.89","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3190.63","","Case rate ($3,437.40). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,867.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4307.80","4307.80","4307.80","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10715.30","","Standard inlier is a Case rate ($10,715.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,882, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,520.99) for the length of stay and the standard reimbursement.","10228.25","10228.24","10715.30","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9386.0226","","Fee schedule rate ($12,784.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9386.0226","12291.76","12291.76","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9855.2757","","Fee schedule rate ($13,423.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9855.2757","13520.35","13520.35","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","MASSHEALTH [3001]","HB NWH MEDICAID","5361.12","","Case rate ($5,775.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,205.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7238.27","7238.27","7238.27","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12972.30","","Fee schedule rate ($12,972.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12972.30","12972.30","12972.30","1 through 10","3190.63","72632.83","case rate",""
"Bronchiolitis And Rsv Pneumonia,MODERATE","138","DRG","","","","","","","","inpatient","","","10224.58","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5361.12","","Case rate ($5,775.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,205.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6266.59","5677.08","7238.27","1 through 10","3190.63","72632.83","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8666.84","","Case rate ($8,414.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,643.88, add-ons for qualifying new technology services are included. If operating cost exceeds $53,786.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,584.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,771.38. The transfer operating threshold is the transfer adjustment factor * $8,643.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $643.02. The transfer capital threshold is the transfer adjustment factor * $643.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8656.08","8656.08","8656.08","1 through 10","8246.12","9559.6963","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","1826.46","1826.46","8780.63","1 through 10","8246.12","9559.6963","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","MEDICARE [2001]","HB NWH MEDICARE","8414.41","","Case rate ($8,414.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,643.88, add-ons for qualifying new technology services are included. If operating cost exceeds $53,786.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,584.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,771.38. The transfer operating threshold is the transfer adjustment factor * $8,643.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $643.02. The transfer capital threshold is the transfer adjustment factor * $643.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9226.34","9226.22","9242.93","27","8246.12","9559.6963","other","Inpatient Replacement Plans DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8246.12","","Case rate ($8,414.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,643.88, add-ons for qualifying new technology services are included. If operating cost exceeds $53,786.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,584.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,771.38. The transfer operating threshold is the transfer adjustment factor * $8,643.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $643.02. The transfer capital threshold is the transfer adjustment factor * $643.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8254.08","8254.08","8254.08","1 through 10","8246.12","9559.6963","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","8246.12","","Case rate ($8,414.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,643.88, add-ons for qualifying new technology services are included. If operating cost exceeds $53,786.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,584.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,771.38. The transfer operating threshold is the transfer adjustment factor * $8,643.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $643.02. The transfer capital threshold is the transfer adjustment factor * $643.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9318.56","9318.56","9318.56","1 through 10","8246.12","9559.6963","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","15625.73","11719.30","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8246.12","","Case rate ($8,414.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,643.88, add-ons for qualifying new technology services are included. If operating cost exceeds $53,786.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,584.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,771.38. The transfer operating threshold is the transfer adjustment factor * $8,643.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $643.02. The transfer capital threshold is the transfer adjustment factor * $643.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8265.08","8265.08","8266.28","1 through 10","8246.12","9559.6963","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","10558.87","7919.15","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","4307.80","4307.80","4307.80","1 through 10","5688.73","6877.55","case rate",""
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","10558.87","7919.15","MEDICARE [2001]","HB NWH MEDICARE","5804.83","","Case rate ($5,804.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,963.14, add-ons for qualifying new technology services are included. If operating cost exceeds $51,105.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,385.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,361.23. The transfer operating threshold is the transfer adjustment factor * $5,963.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.60. The transfer capital threshold is the transfer adjustment factor * $443.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6648.46","6648.46","6648.46","1 through 10","5688.73","6877.55","other","Inpatient Replacement Plans DRG"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","2727.00","2045.25","AETNA [1001]","HB CH AETNA HMO / PPO","1589.84","58.3","","3384.99","3384.99","3384.99","1 through 10","1232.36","2124.61","percent of total billed charges",""
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","2727.00","2045.25","WELLPOINT [1015]","HB CH WELLPOINT","2124.61","77.91","","2350.99","2350.99","2350.99","1 through 10","1232.36","2124.61","percent of total billed charges",""
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","outpatient","","","2727.00","2045.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1130.55","1130.55","1130.55","1 through 10","1169.88","2139.33","other","ASC "
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","outpatient","","","2727.00","2045.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2217.26","2217.26","2217.26","1 through 10","1169.88","2139.33","other","ASC "
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","2917.00","2187.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2015.14","2015.14","2015.14","1 through 10","1232.36","2272.63","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","2917.00","2187.75","MEDICARE [2001]","HB NWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","2047.91","4378.47","1 through 10","1232.36","2272.63","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","2917.00","2187.75","WELLPOINT [1015]","HB CH WELLPOINT","2272.63","77.91","","10671.97","10671.97","10671.97","1 through 10","1232.36","2272.63","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","2822.00","2116.50","MEDICARE [2001]","HB NWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","2047.91","2047.91","1 through 10","1232.36","2198.62","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","2822.00","2116.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2012.35","2012.35","2012.35","1 through 10","1232.36","2198.62","other","OPPS APC"
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","both","","","919.42","689.56","AETNA [1001]","HB CH AETNA HMO / PPO","536.02","58.3","","1786.05","1786.05","1786.05","1 through 10","487.29","823.63","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","919.42","689.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","545.22","59.3","","1845.90","1845.90","1845.90","1 through 10","408.68","721.28","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","919.42","689.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","721.28","78.45","","2421.72","2421.72","2421.72","1 through 10","408.68","721.28","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","AETNA [1001]","HB CH AETNA HMO / PPO","456.49","58.3","","1530.90","1160.93","1884.08","89","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","414.99","53","","5253.92","5253.92","5253.92","1 through 10","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","454.14","58","","12181.47","12181.47","12181.47","1 through 10","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","489.38","62.5","","1350.68","1350.68","1350.68","1 through 10","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.04","44.45","","1910.74","891.94","1910.74","1 through 10","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","WELLPOINT [1015]","HB CH WELLPOINT","610.04","77.91","","1829.79","1561.50","2617.12","88","348.04","610.04","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","464.32","59.3","","1359.46","1201.30","1689.00","61","391.5","614.26","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","464.32","59.3","","1718.92","1718.92","1718.92","1 through 10","391.5","614.26","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","614.26","78.45","","1910.74","1019.06","2344.84","74","391.5","614.26","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","AETNA [1001]","HB CH AETNA HMO / PPO","2425.40","58.3","","1530.90","1160.93","1884.08","89","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2204.91","53","","5253.92","5253.92","5253.92","1 through 10","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2412.92","58","","12181.47","12181.47","12181.47","1 through 10","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2600.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1849.21","44.45","","1910.74","891.94","1910.74","1 through 10","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","4160.20","3120.15","WELLPOINT [1015]","HB CH WELLPOINT","3241.21","77.91","","1829.79","1561.50","2617.12","88","1849.21","3241.21","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4160.20","3120.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","2467.00","59.3","","1359.46","1201.30","1689.00","61","2080.1","3263.68","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4160.20","3120.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2467.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2080.1","3263.68","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4160.20","3120.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3263.68","78.45","","1910.74","1019.06","2344.84","74","2080.1","3263.68","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","AETNA [1001]","HB CH AETNA HMO / PPO","247.78","58.3","","464.71","67.87","1012.10","221","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","247.78","58.3","","293.04","293.04","293.04","11","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.26","53","","983.89","983.89","983.89","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","246.51","58","","677.18","677.18","677.18","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.63","62.5","","46.58","46.58","46.58","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.26","73","","747.15","747.15","747.15","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.92","44.45","","1141.67","481.21","1141.67","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.92","44.45","","76.54","76.54","76.54","1 through 10","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","WELLPOINT [1015]","HB CH WELLPOINT","331.13","77.91","","273.64","94.28","1367.51","138","188.92","331.13","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.03","59.3","","720.78","230.14","2010.94","427","212.51","333.42","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","252.03","59.3","","344.45","344.45","344.45","1 through 10","212.51","333.42","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","333.42","78.45","","1120.13","1120.13","1120.13","1 through 10","212.51","333.42","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","333.42","78.45","","456.17","105.33","1284.66","242","212.51","333.42","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","AETNA [1001]","HB CH AETNA HMO / PPO","787.05","58.3","","1530.90","1160.93","1884.08","89","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.50","53","","5253.92","5253.92","5253.92","1 through 10","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","783.00","58","","12181.47","12181.47","12181.47","1 through 10","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","843.75","62.5","","1350.68","1350.68","1350.68","1 through 10","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.08","44.45","","1910.74","891.94","1910.74","1 through 10","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","WELLPOINT [1015]","HB CH WELLPOINT","1051.79","77.91","","1829.79","1561.50","2617.12","88","600.08","1051.79","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","800.55","59.3","","1359.46","1201.30","1689.00","61","675","1059.08","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","800.55","59.3","","1718.92","1718.92","1718.92","1 through 10","675","1059.08","percent of total billed charges",""
"BUTTON FEMORAL 4.0 XMM KNEE HEMICAP TROCHLEAR ARTICULAR OFFSET P206-0040-W","SUP-ITM-10158289","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.08","78.45","","1910.74","1019.06","2344.84","74","675","1059.08","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","AETNA [1001]","HB CH AETNA HMO / PPO","250.11","58.3","","464.71","67.87","1012.10","221","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","250.11","58.3","","293.04","293.04","293.04","11","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","227.37","53","","983.89","983.89","983.89","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","248.82","58","","677.18","677.18","677.18","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","268.13","62.5","","46.58","46.58","46.58","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","313.17","73","","747.15","747.15","747.15","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.69","44.45","","1141.67","481.21","1141.67","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.69","44.45","","76.54","76.54","76.54","1 through 10","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","WELLPOINT [1015]","HB CH WELLPOINT","334.23","77.91","","273.64","94.28","1367.51","138","190.69","334.23","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","254.40","59.3","","720.78","230.14","2010.94","427","214.5","336.55","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","254.40","59.3","","344.45","344.45","344.45","1 through 10","214.5","336.55","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","336.55","78.45","","1120.13","1120.13","1120.13","1 through 10","214.5","336.55","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","336.55","78.45","","456.17","105.33","1284.66","242","214.5","336.55","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","AETNA [1001]","HB CH AETNA HMO / PPO","514.21","58.3","","1530.90","1160.93","1884.08","89","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","467.46","53","","5253.92","5253.92","5253.92","1 through 10","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","511.56","58","","12181.47","12181.47","12181.47","1 through 10","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","551.25","62.5","","1350.68","1350.68","1350.68","1 through 10","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.05","44.45","","1910.74","891.94","1910.74","1 through 10","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","WELLPOINT [1015]","HB CH WELLPOINT","687.17","77.91","","1829.79","1561.50","2617.12","88","392.05","687.17","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.03","59.3","","1359.46","1201.30","1689.00","61","441","691.93","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.03","59.3","","1718.92","1718.92","1718.92","1 through 10","441","691.93","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.93","78.45","","1910.74","1019.06","2344.84","74","441","691.93","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","AETNA [1001]","HB CH AETNA HMO / PPO","701.35","58.3","","464.71","67.87","1012.10","221","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","701.35","58.3","","293.04","293.04","293.04","11","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","637.59","53","","983.89","983.89","983.89","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","697.74","58","","677.18","677.18","677.18","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","751.88","62.5","","46.58","46.58","46.58","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","878.19","73","","747.15","747.15","747.15","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","1141.67","481.21","1141.67","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","76.54","76.54","76.54","1 through 10","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","WELLPOINT [1015]","HB CH WELLPOINT","937.26","77.91","","273.64","94.28","1367.51","138","534.73","937.26","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","713.38","59.3","","720.78","230.14","2010.94","427","601.5","943.75","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","713.38","59.3","","344.45","344.45","344.45","1 through 10","601.5","943.75","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","1120.13","1120.13","1120.13","1 through 10","601.5","943.75","percent of total billed charges",""
"BUTTON SUTURE 15MM ENDOBUTTON XTEND","SUP-ITM-10107410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","456.17","105.33","1284.66","242","601.5","943.75","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","AETNA [1001]","HB CH AETNA HMO / PPO","760.82","58.3","","464.71","67.87","1012.10","221","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","760.82","58.3","","293.04","293.04","293.04","11","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.65","53","","983.89","983.89","983.89","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","756.90","58","","677.18","677.18","677.18","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","815.63","62.5","","46.58","46.58","46.58","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","952.65","73","","747.15","747.15","747.15","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.07","44.45","","1141.67","481.21","1141.67","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.07","44.45","","76.54","76.54","76.54","1 through 10","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","WELLPOINT [1015]","HB CH WELLPOINT","1016.73","77.91","","273.64","94.28","1367.51","138","580.07","1016.73","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.87","59.3","","720.78","230.14","2010.94","427","652.5","1023.77","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","773.87","59.3","","344.45","344.45","344.45","1 through 10","652.5","1023.77","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1023.77","78.45","","1120.13","1120.13","1120.13","1 through 10","652.5","1023.77","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.77","78.45","","456.17","105.33","1284.66","242","652.5","1023.77","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","464.71","67.87","1012.10","221","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","293.04","293.04","293.04","11","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","983.89","983.89","983.89","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","513.30","58","","677.18","677.18","677.18","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","553.13","62.5","","46.58","46.58","46.58","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","747.15","747.15","747.15","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","1141.67","481.21","1141.67","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","76.54","76.54","76.54","1 through 10","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","273.64","94.28","1367.51","138","393.38","689.5","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","720.78","230.14","2010.94","427","442.5","694.28","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","524.81","59.3","","344.45","344.45","344.45","1 through 10","442.5","694.28","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","1120.13","1120.13","1120.13","1 through 10","442.5","694.28","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM TRACTION FIXATION TITANIUM PEC REPAIR","SUP-ITM-10092103","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","456.17","105.33","1284.66","242","442.5","694.28","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","AETNA [1001]","HB CH AETNA HMO / PPO","391.78","58.3","","464.71","67.87","1012.10","221","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","391.78","58.3","","293.04","293.04","293.04","11","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","356.16","53","","983.89","983.89","983.89","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","389.76","58","","677.18","677.18","677.18","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","420.00","62.5","","46.58","46.58","46.58","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","747.15","747.15","747.15","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","1141.67","481.21","1141.67","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","76.54","76.54","76.54","1 through 10","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","273.64","94.28","1367.51","138","298.7","523.56","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","398.50","59.3","","720.78","230.14","2010.94","427","336","527.18","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","398.50","59.3","","344.45","344.45","344.45","1 through 10","336","527.18","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","1120.13","1120.13","1120.13","1 through 10","336","527.18","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","456.17","105.33","1284.66","242","336","527.18","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","464.71","67.87","1012.10","221","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","293.04","293.04","293.04","11","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","983.89","983.89","983.89","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","609.00","58","","677.18","677.18","677.18","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","656.25","62.5","","46.58","46.58","46.58","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","747.15","747.15","747.15","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","1141.67","481.21","1141.67","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","76.54","76.54","76.54","1 through 10","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","273.64","94.28","1367.51","138","466.73","818.06","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","720.78","230.14","2010.94","427","525","823.73","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","622.65","59.3","","344.45","344.45","344.45","1 through 10","525","823.73","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","1120.13","1120.13","1120.13","1 through 10","525","823.73","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","456.17","105.33","1284.66","242","525","823.73","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","AETNA [1001]","HB CH AETNA HMO / PPO","321.82","58.3","","464.71","67.87","1012.10","221","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","321.82","58.3","","293.04","293.04","293.04","11","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","292.56","53","","983.89","983.89","983.89","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","320.16","58","","677.18","677.18","677.18","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","345.00","62.5","","46.58","46.58","46.58","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","402.96","73","","747.15","747.15","747.15","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.36","44.45","","1141.67","481.21","1141.67","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.36","44.45","","76.54","76.54","76.54","1 through 10","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.00","414.00","WELLPOINT [1015]","HB CH WELLPOINT","430.06","77.91","","273.64","94.28","1367.51","138","245.36","430.06","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.00","414.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","327.34","59.3","","720.78","230.14","2010.94","427","276","433.04","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.00","414.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","327.34","59.3","","344.45","344.45","344.45","1 through 10","276","433.04","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.00","414.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","433.04","78.45","","1120.13","1120.13","1120.13","1 through 10","276","433.04","percent of total billed charges",""
"BUTTON WIRE 8.0X12MM FIXATION 2 PC TIGHTROPE ABS UHMWPE IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10126244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.00","414.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","433.04","78.45","","456.17","105.33","1284.66","242","276","433.04","percent of total billed charges",""
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","both","","","4917.00","3687.75","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","3589.41","other","OPPS APC"
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","both","","","4917.00","3687.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","313.68","104.56","313.68","1 through 10","99.34","3589.41","other","OPPS APC"
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","both","","","4917.00","3687.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.67","102.47","102.67","1 through 10","99.34","3589.41","other","OPPS APC"
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","outpatient","","","4917.00","3687.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2412.77","49.07","","3641.00","3641.00","3641.00","1 through 10","142.04","2463.42","percent of total billed charges",""
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","outpatient","","","4917.00","3687.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2463.42","50.1","","188.55","188.55","188.55","1 through 10","142.04","2463.42","percent of total billed charges",""
"Bwf Body&Colon Screen-Patient","PX-35000093","CDM","76497","CPT","0350","RC","","","","outpatient","","","4917.00","3687.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1747.50","35.54","","1268.16","1268.16","1268.16","1 through 10","142.04","2463.42","percent of total billed charges",""
"Bwf Fungitell Assay Titre","PX-30001751","CDM","84999","CPT","0300","RC","","","","outpatient","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.45","78.45","","38.44","38.44","38.44","1 through 10","4.28","402.45","percent of total billed charges",""
"Bwf Ia,Antig Det by Ia,Not Sp Add","PX-30001761","CDM","87899","CPT","0300","RC","","","","both","","","141.00","105.75","AETNA [1001]","HB CH AETNA HMO / PPO","82.20","58.3","","216.59","216.59","216.59","1 through 10","15.75","133.95","percent of total billed charges",""
"Bwf Oncotype Dx","PX-31000222","CDM","84999","CPT","0310","RC","","","","outpatient","","","18222.00","13666.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","14295.16","78.45","","38.44","38.44","38.44","1 through 10","28.31","14295.16","percent of total billed charges",""
"Bwf Unlisted Chem Procedure","PX-30001752","CDM","84999","CPT","0300","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","204.75","78.45","","38.44","38.44","38.44","1 through 10","4.28","204.75","percent of total billed charges",""
"Bwf Unlisted Chemistry Test","PX-30001750","CDM","84999","CPT","0300","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","204.75","78.45","","38.44","38.44","38.44","1 through 10","4.28","204.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","172.62","71.69","172.62","72","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","116.02","63.4","","243.20","233.60","243.20","1 through 10","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","TRICARE [160005]","HB NWH TRICARE","173.85","95","","82.92","39.39","148.66","13","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","32.31","29.62","38.35","70","38.35","174.03","fee schedule",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","104.31","1 through 10","91.5","254.62","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","183.00","137.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","105.59","57.7","","212.80","212.80","212.80","1 through 10","91.5","254.62","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","183.00","137.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","110.72","60.5","","21919.63","276.80","21919.63","1 through 10","91.5","254.62","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","2493.00","1869.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1248.99","50.1","","248.00","248.00","248.00","1 through 10","1069.5","1955.76","percent of total billed charges",""
"Bx Breast 1st Lesion MR Imag","PX-76001934","CDM","19085","CPT","0761","RC","","","","both","","","2359.00","1769.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5105.36","2294.00","5105.36","1 through 10","1237.95","1981.66","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","AETNA [1001]","HB CH AETNA HMO / PPO","1375.30","58.3","","1300.70","1300.70","1300.70","1 through 10","1237.95","1981.66","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2482.77","2266.14","4970.75","11","1237.95","1981.66","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1889.50","1893.55","1 through 10","1237.95","1981.66","other","OPPS APC"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3057.74","3057.74","3057.74","1 through 10","1048.58","2959.67","other","Multiple Surgery"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","2359.00","1769.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2620.88","2094.09","3554.17","1 through 10","1237.95","1981.66","other","Multiple Surgery"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1885.65","1893.55","12","1237.95","1981.66","other","OPPS APC"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1048.58","2959.67","other","Multiple Surgery"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6569.63","3057.74","6569.63","1 through 10","1048.58","2959.67","other","Multiple Surgery"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1850.64","78.45","","3746.10","3746.10","3746.10","1 through 10","1048.58","2959.67","percent of total billed charges",""
"Bx Breast Add Lesion MR Imag","PX-76001935","CDM","19086","CPT","0761","RC","","","","both","","","459.00","344.25","WELLPOINT [1015]","HB CH WELLPOINT","357.61","77.91","","351.27","351.27","351.27","1 through 10","243.27","357.61","percent of total billed charges",""
"Bx Breast Add Lesion Strtctc","PX-76001931","CDM","19082","CPT","0761","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","826.00","826.00","826.00","1 through 10","231.61","340.47","per diem",""
"Bx Breast Add Lesion Strtctc","PX-76001931","CDM","19082","CPT","0761","RC","","","","outpatient","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","342.83","78.45","","313.18","313.18","313.18","1 through 10","142.38","342.83","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","243.00","182.25","AETNA [1001]","HB CH AETNA HMO / PPO","141.67","58.3","","133.81","133.81","133.81","13","20.39","230.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","243.00","182.25","TRICARE [160005]","HB NWH TRICARE","230.85","95","","23.83","23.83","23.83","1 through 10","20.39","230.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","243.00","182.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.01","44.45","","107.52","107.52","107.52","1 through 10","20.39","230.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","243.00","182.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.10","59.3","","138.30","138.30","138.30","1 through 10","21.45","190.63","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","190.63","78.45","","181.44","107.52","181.44","1 through 10","21.45","190.63","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0300","RC","","","","inpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.16","56","","32.62","32.62","32.62","1 through 10","34.16","43.07","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0300","RC","","","","inpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.07","70.6","","26.88","26.88","26.88","1 through 10","34.16","43.07","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","303","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","43.07","43.07","43.07","1 through 10","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.33","53","","41.87","41.87","41.87","1 through 10","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","TRICARE [160005]","HB NWH TRICARE","57.95","95","","6.24","5.93","6.24","15","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","43.22","26.88","45.36","20","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","26.88","26.88","26.88","1 through 10","5.08","57.95","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","36.61","321","5.34","47.85","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","45.36","45.36","1 through 10","5.34","47.85","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","284","5.34","47.85","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","89","12.69","101.65","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.11","73","","104.00","11.66","104.00","1 through 10","12.69","101.65","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","TRICARE [160005]","HB NWH TRICARE","101.65","95","","15.60","14.82","15.60","1 through 10","12.69","101.65","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.56","44.45","","79.96","47.38","79.96","1 through 10","12.69","101.65","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","94","13.35","83.94","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","13.35","83.94","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","79.96","47.38","79.96","105","13.35","83.94","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","50","11.76","135.85","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","104.39","73","","202.94","202.94","202.94","1 through 10","11.76","135.85","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB NWH TRICARE","135.85","95","","28.92","28.92","28.92","1 through 10","11.76","135.85","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","44.45","","106.87","106.87","106.87","1 through 10","11.76","135.85","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","244.36","57","12.38","112.18","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","106.87","49","12.38","112.18","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","50","11.76","135.85","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","104.39","73","","202.94","202.94","202.94","1 through 10","11.76","135.85","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB NWH TRICARE","135.85","95","","28.92","28.92","28.92","1 through 10","11.76","135.85","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","44.45","","106.87","106.87","106.87","1 through 10","11.76","135.85","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","244.36","57","12.38","112.18","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","106.87","49","12.38","112.18","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","AETNA [1001]","HB CH AETNA HMO / PPO","1822.46","58.3","","464.71","67.87","1012.10","221","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1822.46","58.3","","293.04","293.04","293.04","11","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1656.78","53","","983.89","983.89","983.89","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1813.08","58","","677.18","677.18","677.18","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1953.75","62.5","","46.58","46.58","46.58","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2281.98","73","","747.15","747.15","747.15","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1389.51","44.45","","1141.67","481.21","1141.67","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1389.51","44.45","","76.54","76.54","76.54","1 through 10","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","WELLPOINT [1015]","HB CH WELLPOINT","2435.47","77.91","","273.64","94.28","1367.51","138","1389.51","2435.47","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1853.72","59.3","","720.78","230.14","2010.94","427","1563","2452.35","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1853.72","59.3","","344.45","344.45","344.45","1 through 10","1563","2452.35","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2452.35","78.45","","1120.13","1120.13","1120.13","1 through 10","1563","2452.35","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2452.35","78.45","","456.17","105.33","1284.66","242","1563","2452.35","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","AETNA [1001]","HB CH AETNA HMO / PPO","853.51","58.3","","464.71","67.87","1012.10","221","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","853.51","58.3","","293.04","293.04","293.04","11","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","775.92","53","","983.89","983.89","983.89","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","849.12","58","","677.18","677.18","677.18","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","915.00","62.5","","46.58","46.58","46.58","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1068.72","73","","747.15","747.15","747.15","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","650.75","44.45","","1141.67","481.21","1141.67","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","650.75","44.45","","76.54","76.54","76.54","1 through 10","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","WELLPOINT [1015]","HB CH WELLPOINT","1140.60","77.91","","273.64","94.28","1367.51","138","650.75","1140.6","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","868.15","59.3","","720.78","230.14","2010.94","427","732","1148.51","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","868.15","59.3","","344.45","344.45","344.45","1 through 10","732","1148.51","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1148.51","78.45","","1120.13","1120.13","1120.13","1 through 10","732","1148.51","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1148.51","78.45","","456.17","105.33","1284.66","242","732","1148.51","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","AETNA [1001]","HB CH AETNA HMO / PPO","434.63","58.3","","464.71","67.87","1012.10","221","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","434.63","58.3","","293.04","293.04","293.04","11","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","395.12","53","","983.89","983.89","983.89","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","432.39","58","","677.18","677.18","677.18","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","465.94","62.5","","46.58","46.58","46.58","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","544.22","73","","747.15","747.15","747.15","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.37","44.45","","1141.67","481.21","1141.67","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.37","44.45","","76.54","76.54","76.54","1 through 10","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","WELLPOINT [1015]","HB CH WELLPOINT","580.82","77.91","","273.64","94.28","1367.51","138","331.37","580.82","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","442.08","59.3","","720.78","230.14","2010.94","427","372.75","584.84","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","442.08","59.3","","344.45","344.45","344.45","1 through 10","372.75","584.84","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","584.84","78.45","","1120.13","1120.13","1120.13","1 through 10","372.75","584.84","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","584.84","78.45","","456.17","105.33","1284.66","242","372.75","584.84","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","AETNA [1001]","HB CH AETNA HMO / PPO","237.86","58.3","","464.71","67.87","1012.10","221","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.86","58.3","","293.04","293.04","293.04","11","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.24","53","","983.89","983.89","983.89","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","236.64","58","","677.18","677.18","677.18","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","255.00","62.5","","46.58","46.58","46.58","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.84","73","","747.15","747.15","747.15","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.36","44.45","","1141.67","481.21","1141.67","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.36","44.45","","76.54","76.54","76.54","1 through 10","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","WELLPOINT [1015]","HB CH WELLPOINT","317.87","77.91","","273.64","94.28","1367.51","138","181.36","317.87","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.94","59.3","","720.78","230.14","2010.94","427","204","320.08","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","241.94","59.3","","344.45","344.45","344.45","1 through 10","204","320.08","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","1120.13","1120.13","1120.13","1 through 10","204","320.08","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","456.17","105.33","1284.66","242","204","320.08","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","AETNA [1001]","HB CH AETNA HMO / PPO","624.48","58.3","","464.71","67.87","1012.10","221","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","624.48","58.3","","293.04","293.04","293.04","11","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","567.71","53","","983.89","983.89","983.89","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","621.27","58","","677.18","677.18","677.18","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","669.47","62.5","","46.58","46.58","46.58","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","781.94","73","","747.15","747.15","747.15","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","476.13","44.45","","1141.67","481.21","1141.67","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","476.13","44.45","","76.54","76.54","76.54","1 through 10","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","WELLPOINT [1015]","HB CH WELLPOINT","834.53","77.91","","273.64","94.28","1367.51","138","476.13","834.53","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","635.19","59.3","","720.78","230.14","2010.94","427","535.58","840.32","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","635.19","59.3","","344.45","344.45","344.45","1 through 10","535.58","840.32","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","840.32","78.45","","1120.13","1120.13","1120.13","1 through 10","535.58","840.32","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","840.32","78.45","","456.17","105.33","1284.66","242","535.58","840.32","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","AETNA [1001]","HB CH AETNA HMO / PPO","303.45","58.3","","464.71","67.87","1012.10","221","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","303.45","58.3","","293.04","293.04","293.04","11","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","275.87","53","","983.89","983.89","983.89","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","301.89","58","","677.18","677.18","677.18","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","325.31","62.5","","46.58","46.58","46.58","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","379.97","73","","747.15","747.15","747.15","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.36","44.45","","1141.67","481.21","1141.67","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.36","44.45","","76.54","76.54","76.54","1 through 10","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","WELLPOINT [1015]","HB CH WELLPOINT","405.52","77.91","","273.64","94.28","1367.51","138","231.36","405.52","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","308.66","59.3","","720.78","230.14","2010.94","427","260.25","408.33","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","308.66","59.3","","344.45","344.45","344.45","1 through 10","260.25","408.33","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","408.33","78.45","","1120.13","1120.13","1120.13","1 through 10","260.25","408.33","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","408.33","78.45","","456.17","105.33","1284.66","242","260.25","408.33","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB CH AETNA HMO / PPO","111.94","58.3","","106.03","106.03","106.03","1 through 10","23.17","182.4","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","192.00","144.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.86","59.3","","109.58","109.58","109.58","1 through 10","23.87","150.62","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.62","78.45","","143.76","85.20","143.77","1 through 10","23.87","150.62","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","AETNA [1001]","HB CH AETNA HMO / PPO","4430.80","58.3","","1530.90","1160.93","1884.08","89","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4028.00","53","","5253.92","5253.92","5253.92","1 through 10","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4408.00","58","","12181.47","12181.47","12181.47","1 through 10","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3378.20","44.45","","1910.74","891.94","1910.74","1 through 10","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","WELLPOINT [1015]","HB CH WELLPOINT","5921.16","77.91","","1829.79","1561.50","2617.12","88","3378.2","5921.16","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7600.00","5700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4506.80","59.3","","1359.46","1201.30","1689.00","61","3800","5962.2","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7600.00","5700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4506.80","59.3","","1718.92","1718.92","1718.92","1 through 10","3800","5962.2","percent of total billed charges",""
"CAGE HUMERAL SZ 2 EQUINOXE ITOTAL IDENTITY CR MEDIAL STEMLESS LASER","SUP-ITM-10286913","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7600.00","5700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5962.20","78.45","","1910.74","1019.06","2344.84","74","3800","5962.2","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","26.25","209.95","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","27.61","173.37","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.48","84.48","84.48","1 through 10","13.41","145.35","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.31","1 through 10","14.1","120.03","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","67.88","67.88","114.55","1 through 10","14.1","120.03","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","71.00","53.25","AETNA [1001]","HB CH AETNA HMO / PPO","41.39","58.3","","39.12","39.12","39.12","11","5.91","67.45","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.56","44.45","","53.05","53.05","53.05","1 through 10","5.91","67.45","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","71.00","53.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","40.43","11","6.23","55.7","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","31.44","53.05","12","6.23","55.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","25","5.06","57","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","26.42","22.55","44.59","1 through 10","5.06","57","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","19","5.33","47.07","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","28","5.33","47.07","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.78","82.78","165.56","12","12.64","142.5","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","77.38","77.38","77.38","1 through 10","12.64","142.5","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","85.56","83.51","85.56","1 through 10","13.29","117.68","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","112.24","66.52","112.24","1 through 10","13.29","117.68","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","125.31","125.31","125.31","46","19.24","215.65","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","TRICARE [160005]","HB NWH TRICARE","215.65","95","","23.65","23.65","23.65","1 through 10","19.24","215.65","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.90","44.45","","100.69","99.23","163.03","1 through 10","19.24","215.65","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","227.00","170.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.61","59.3","","129.51","129.51","458.83","16","20.24","178.08","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","227.00","170.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","169.90","169.90","169.90","1 through 10","20.24","178.08","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","169.90","100.69","169.90","40","20.24","178.08","percent of total billed charges",""
"Calr Gene Analysis Common Variants in Exon 9","PX-31000694","CDM","81219","CPT","0310","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","327.30","49.07","","370.25","370.25","370.25","1 through 10","327.3","523.26","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","AETNA [1001]","HB CH AETNA HMO / PPO","7.37","58.3","","464.71","67.87","1012.10","221","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7.37","58.3","","293.04","293.04","293.04","11","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.70","53","","983.89","983.89","983.89","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7.34","58","","677.18","677.18","677.18","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7.91","62.5","","46.58","46.58","46.58","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9.23","73","","747.15","747.15","747.15","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.62","44.45","","1141.67","481.21","1141.67","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.62","44.45","","76.54","76.54","76.54","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","WELLPOINT [1015]","HB CH WELLPOINT","9.86","77.91","","273.64","94.28","1367.51","138","5.62","9.86","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","7.50","59.3","","720.78","230.14","2010.94","427","6.33","9.92","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7.50","59.3","","344.45","344.45","344.45","1 through 10","6.33","9.92","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","9.92","78.45","","1120.13","1120.13","1120.13","1 through 10","6.33","9.92","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9.92","78.45","","456.17","105.33","1284.66","242","6.33","9.92","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","AETNA [1001]","HB CH AETNA HMO / PPO","7.37","58.3","","464.71","67.87","1012.10","221","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7.37","58.3","","293.04","293.04","293.04","11","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.70","53","","983.89","983.89","983.89","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7.34","58","","677.18","677.18","677.18","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7.91","62.5","","46.58","46.58","46.58","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9.23","73","","747.15","747.15","747.15","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.62","44.45","","1141.67","481.21","1141.67","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.62","44.45","","76.54","76.54","76.54","1 through 10","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.65","9.49","WELLPOINT [1015]","HB CH WELLPOINT","9.86","77.91","","273.64","94.28","1367.51","138","5.62","9.86","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","7.50","59.3","","720.78","230.14","2010.94","427","6.33","9.92","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7.50","59.3","","344.45","344.45","344.45","1 through 10","6.33","9.92","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","9.92","78.45","","1120.13","1120.13","1120.13","1 through 10","6.33","9.92","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.65","9.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9.92","78.45","","456.17","105.33","1284.66","242","6.33","9.92","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","AETNA [1001]","HB CH AETNA HMO / PPO","501.82","58.3","","464.71","67.87","1012.10","221","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","501.82","58.3","","293.04","293.04","293.04","11","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","456.20","53","","983.89","983.89","983.89","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","499.24","58","","677.18","677.18","677.18","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","537.98","62.5","","46.58","46.58","46.58","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","628.35","73","","747.15","747.15","747.15","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.61","44.45","","1141.67","481.21","1141.67","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.61","44.45","","76.54","76.54","76.54","1 through 10","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","WELLPOINT [1015]","HB CH WELLPOINT","670.62","77.91","","273.64","94.28","1367.51","138","382.61","670.62","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","510.43","59.3","","720.78","230.14","2010.94","427","430.38","675.27","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","510.43","59.3","","344.45","344.45","344.45","1 through 10","430.38","675.27","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","675.27","78.45","","1120.13","1120.13","1120.13","1 through 10","430.38","675.27","percent of total billed charges",""
"CAP END 11.5MM 8 NAIL T2 TITANIUM STANDARD PLUS","SUP-ITM-10028281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","675.27","78.45","","456.17","105.33","1284.66","242","430.38","675.27","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","AETNA [1001]","HB CH AETNA HMO / PPO","284.09","58.3","","464.71","67.87","1012.10","221","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.09","58.3","","293.04","293.04","293.04","11","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.26","53","","983.89","983.89","983.89","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.63","58","","677.18","677.18","677.18","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.56","62.5","","46.58","46.58","46.58","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.72","73","","747.15","747.15","747.15","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.60","44.45","","1141.67","481.21","1141.67","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.60","44.45","","76.54","76.54","76.54","1 through 10","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","WELLPOINT [1015]","HB CH WELLPOINT","379.65","77.91","","273.64","94.28","1367.51","138","216.6","379.65","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.96","59.3","","720.78","230.14","2010.94","427","243.65","382.28","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","288.96","59.3","","344.45","344.45","344.45","1 through 10","243.65","382.28","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","382.28","78.45","","1120.13","1120.13","1120.13","1 through 10","243.65","382.28","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.28","78.45","","456.17","105.33","1284.66","242","243.65","382.28","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","2190.90","412.50","9264.59","16","33.34","58.43","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","1903.20","1903.20","3826.66","1 through 10","33.34","58.43","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","2186.25","2186.25","2186.25","32","33.34","58.43","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","5556.60","5556.60","5556.60","1 through 10","33.34","58.43","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","1955.15","885.83","3150.40","26","33.34","58.43","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","831.03","253.22","2394.88","18","37.5","58.84","percent of total billed charges",""
"CAP LOCKING LANX TITANIUM","SUP-ITM-10104640","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2481.69","1563.74","8149.28","1 through 10","37.5","58.84","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","14.28","114","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","1 through 10","15.03","94.14","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","53.31","53.31","89.95","1 through 10","15.03","94.14","percent of total billed charges",""
"Carbohydrate Deficient Transferrin","PX-30002316","CDM","82373","CPT","0301","RC","","","","both","","","216.00","162.00","AETNA [1001]","HB CH AETNA HMO / PPO","125.93","58.3","","119.07","119.07","119.07","1 through 10","17.7","205.2","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","outpatient","","","100.00","75.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.30","59.3","","153.84","56.84","153.84","1 through 10","12.71","78.45","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","255.20","58","","148.01","148.01","148.01","1 through 10","195.58","321.2","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","255.20","58","","174.13","174.13","174.13","1 through 10","195.58","321.2","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","267.96","60.9","","182.84","174.13","182.84","1 through 10","195.58","321.2","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","275.00","62.5","","191.89","191.89","575.67","25","195.58","321.2","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","321.20","73","","218.28","218.28","218.28","1 through 10","195.58","321.2","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","440.00","330.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","260.92","59.3","","250.81","250.81","250.81","14","220","345.18","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","345.18","78.45","","329.05","195.00","329.05","20","220","345.18","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","87.89","87.89","87.89","14","18.58","151.05","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","159.00","119.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","45","19.56","124.74","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","159.00","119.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","1 through 10","19.56","124.74","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","124.74","78.45","","119.16","70.62","119.16","12","19.56","124.74","percent of total billed charges",""
"Cardiac Arrest And Shock,MAJOR","196","DRG","","","","","","","","inpatient","","","27939.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22028.39","","Standard inlier is a Case rate ($22,028.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,685, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,126.84) for the length of stay and the standard reimbursement.","175.48","175.48","175.48","1 through 10","8053.36","51103.52","case rate",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6565.27","","Case rate ($6,374.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,886.95. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6618.82","6616.82","6618.82","1 through 10","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7008.43","","Case rate ($7,008.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,521.33. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6375.33","6375.24","6955.58","1 through 10","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","7008.43","","Case rate ($7,008.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,521.33. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20679.46","20679.46","20679.46","1 through 10","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","MEDICARE [2001]","HB NWH MEDICARE","7008.43","","Case rate ($7,008.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,521.33. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7056.00","1470.03","7068.68","87","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6246.57","","Case rate ($6,374.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,886.95. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6307.73","30.11","6335.16","1 through 10","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","18560.79","13920.59","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6246.57","","Case rate ($6,374.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,547.88, add-ons for qualifying new technology services are included. If operating cost exceeds $51,690.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,429.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,886.95. The transfer operating threshold is the transfer adjustment factor * $6,547.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6325.44","6313.85","6432.29","1 through 10","6246.57","7551.96","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","10744.32","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9546.37","9546.37","9546.37","1 through 10","10222.75","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","10431.38","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11345.52","11345.52","11345.52","1 through 10","10222.75","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","10431.38","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10491.95","10491.95","10491.95","1 through 10","10222.75","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","MEDICARE [2001]","HB NWH MEDICARE","10431.38","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11509.31","2082.77","11530.00","35","10222.75","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10222.75","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10286.11","10284.99","10322.11","1 through 10","10222.75","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","28831.01","21623.26","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","10222.75","","Case rate ($10,431.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,715.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,858.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,739.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,634.21. The transfer operating threshold is the transfer adjustment factor * $10,715.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.15. The transfer capital threshold is the transfer adjustment factor * $797.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10294.80","10278.99","10302.55","1 through 10","10222.75","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","17201.94","12901.45","MEDICARE [2001]","HB NWH MEDICARE","4904.65","","Case rate ($4,904.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,038.40, add-ons for qualifying new technology services are included. If operating cost exceeds $50,180.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,316.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,529.84. The transfer operating threshold is the transfer adjustment factor * $5,038.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.81. The transfer capital threshold is the transfer adjustment factor * $374.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5339.91","701.03","5349.57","1 through 10","4806.56","5532.8955","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","17201.94","12901.45","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4806.56","","Case rate ($4,904.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,038.40, add-ons for qualifying new technology services are included. If operating cost exceeds $50,180.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,316.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,529.84. The transfer operating threshold is the transfer adjustment factor * $5,038.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.81. The transfer capital threshold is the transfer adjustment factor * $374.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4771.15","4771.15","4771.15","1 through 10","4806.56","5532.8955","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","22747.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20720.08","","Standard inlier is a Case rate ($20,720.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,905, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,941.30) for the length of stay and the standard reimbursement.","34031.72","34031.72","34031.72","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","22747.11","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8782.1748","","Fee schedule rate ($47,141.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8782.1748","47141.16","47141.16","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20720.08","","Standard inlier is a Case rate ($20,720.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,905, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,941.30) for the length of stay and the standard reimbursement.","20720.07","20720.07","20720.07","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22257.50","","Standard inlier is a Case rate ($22,257.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,905, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,159.36) for the length of stay and the standard reimbursement.","9478.07","2575.32","22257.49","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","MASSHEALTH [3001]","HB NWH MEDICAID","8430.66","","Case rate ($9,082.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,512.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5518.83","5518.83","9106.06","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","8430.66","","Case rate ($9,082.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,512.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","17698.12","","Fee schedule rate ($17,698.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9424.25","9424.25","9424.25","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37722.69","","Fee schedule rate ($37,722.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20087.33","20087.33","20087.33","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","22755.94","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8430.66","","Case rate ($9,082.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,512.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9106.06","9106.06","9106.06","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","17479.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10700.80","","Standard inlier is a Case rate ($10,700.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,519.02) for the length of stay and the standard reimbursement.","10214.53","10214.53","10214.53","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","17479.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11494.79","","Standard inlier is a Case rate ($11,494.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,631.64) for the length of stay and the standard reimbursement.","10972.30","10972.30","10972.30","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","17479.34","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","9660.30","","Fee schedule rate ($9,660.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9660.32","9660.32","9660.32","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13873.04","","Standard inlier is a Case rate ($13,873.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,969.33) for the length of stay and the standard reimbursement.","13243.45","13242.62","13873.03","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14902.41","","Standard inlier is a Case rate ($14,902.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,115.33) for the length of stay and the standard reimbursement.","14225.02","7202.22","14902.41","15","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8782.1748","","Per diem ($4,250). If length of stay < 3, first 1 days paid at a per diem of $8,500 instead.","8782.1748","12749.20","12749.20","1 through 10","2205","77782.2","per diem","Estimated amount calculated based on 1 day length of stay."
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9221.2386","","Per diem ($4,462). If length of stay < 3, first 1 days paid at a per diem of $8,924 instead.","9221.2386","19367.47","19367.47","1 through 10","2205","77782.2","per diem","Estimated amount calculated based on 1 day length of stay."
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","MASSHEALTH [3001]","HB NWH MEDICAID","4905.32","","Case rate ($5,284.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,714.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,601.43 and the sum of the standard inlier and any outlier amount.","6622.87","6622.87","6622.87","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","2205.00","","Per diem ($2,205). If length of stay < 2.61, first 1 days paid at a per diem of $4,410 instead.","5754.83","5754.83","5754.83","1 through 10","2205","77782.2","per diem","Estimated amount calculated based on 1 day length of stay."
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2594.00","","Per diem ($2,594). If length of stay < 2.61, first 1 days paid at a per diem of $5,188 instead.","6770.39","6770.39","6770.39","1 through 10","2205","77782.2","per diem","Estimated amount calculated based on 1 day length of stay."
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5529.00","","Per diem ($5,529). If length of stay < 2.61, first 1 days paid at a per diem of $11,058 instead.","14430.76","14430.76","14430.76","1 through 10","2205","77782.2","per diem","Estimated amount calculated based on 1 day length of stay."
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","4905.32","","Case rate ($5,284.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,714.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,601.43 and the sum of the standard inlier and any outlier amount.","3211.09","3211.09","3211.09","1 through 10","2205","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18717.22","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4905.32","","Case rate ($5,284.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,714.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,601.43 and the sum of the standard inlier and any outlier amount.","5298.30","5298.30","5298.30","1 through 10","2205","77782.2","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","84563.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","18770.091","","Fee schedule rate ($33,536.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18770.091","33536.02","33536.02","1 through 10","15416.025","55333.93","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","81816.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23828.58","","Standard inlier is a Case rate ($23,828.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,093, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,382.56) for the length of stay and the standard reimbursement.","14723.70","14723.70","14723.70","1 through 10","6985.57","39289.31","case rate",""
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","31783.73","23837.80","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14062.19","","Case rate ($13,652.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,024.95, add-ons for qualifying new technology services are included. If operating cost exceeds $59,167.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,985.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,609.30. The transfer operating threshold is the transfer adjustment factor * $14,024.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.32. The transfer capital threshold is the transfer adjustment factor * $1,043.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13401.91","13401.91","13401.91","1 through 10","13379.56","15011.39","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","31783.73","23837.80","MEDICARE [2001]","HB NWH MEDICARE","15011.39","","Case rate ($15,011.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,024.95, add-ons for qualifying new technology services are included. If operating cost exceeds $59,167.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,985.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $13,968.07. The transfer operating threshold is the transfer adjustment factor * $14,024.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.32. The transfer capital threshold is the transfer adjustment factor * $1,043.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14291.44","14317.14","14317.14","1 through 10","13379.56","15011.39","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","31783.73","23837.80","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13379.56","","Case rate ($13,652.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,024.95, add-ons for qualifying new technology services are included. If operating cost exceeds $59,167.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,985.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,609.30. The transfer operating threshold is the transfer adjustment factor * $14,024.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.32. The transfer capital threshold is the transfer adjustment factor * $1,043.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9823.86","9823.86","9823.86","1 through 10","13379.56","15011.39","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","94502.57","70876.93","MEDICARE [2001]","HB NWH MEDICARE","57220.09","","Case rate ($57,220.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $53,459.97, add-ons for qualifying new technology services are included. If operating cost exceeds $98,602.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,918.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $53,243.19. The transfer operating threshold is the transfer adjustment factor * $53,459.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,976.90. The transfer capital threshold is the transfer adjustment factor * $3,976.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59226.70","59226.70","59226.70","1 through 10","50999.93","61657.75","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement With McC","260","MS-DRG","","","","","","","","inpatient","","","48617.57","36463.18","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","27618.37","","Case rate ($28,182.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,950.58, add-ons for qualifying new technology services are included. If operating cost exceeds $74,092.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,095.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $26,028.38. The transfer operating threshold is the transfer adjustment factor * $28,950.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,153.64. The transfer capital threshold is the transfer adjustment factor * $2,153.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","10194.01","10194.01","10194.01","1 through 10","27618.37","32784.0128","other","Inpatient DRG"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB CH AETNA HMO / PPO","324.15","58.3","","306.75","306.75","306.75","102","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","154.00","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","153.87","153.87","154.47","62","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","141.91","147.14","100","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.71","59.3","","317.03","317.03","317.03","87","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","FALLON HEALTH [1008]","HB NWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.34","141.34","146.54","15","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","MEDICARE [2001]","HB NWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.53","149.53","149.53","1146","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","TRICARE [160005]","HB NWH TRICARE","142.05","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","149.53","149.53","149.53","1 through 10","125.9","459.6","other","Tricare OPPS"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","439.62","232","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","141.34","146.54","100","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","436.18","78.45","","1247.76","415.91","1663.68","60","195.1","436.18","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB CH AETNA HMO / PPO","216.29","58.3","","204.69","204.69","204.69","1 through 10","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","154.00","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","154.47","153.87","154.47","1 through 10","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","147.14","147.14","1 through 10","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","MEDICARE [2001]","HB NWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.53","144.22","149.53","102","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","439.62","23","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","141.84","293.08","88","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","371.00","278.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","220.00","59.3","","211.55","211.55","211.55","12","164.91","341.55","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","291.05","78.45","","277.54","277.54","277.54","1 through 10","164.91","341.55","percent of total billed charges",""
"Cardiac Structural And Valvular Disorders,EXTREME","200","DRG","","","","","","","","inpatient","","","40792.86","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9380.16","","Per diem ($18,039). If length of stay < 5, first 1 days paid at a per diem of $36,078 instead.","9380.16","72156.88","72156.88","1 through 10","2837","29764","per diem","Estimated amount calculated based on 3 day length of stay."
"Cardiac Structural And Valvular Disorders,MINOR","200","DRG","","","","","","","","inpatient","","","26634.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11107.68","","Standard inlier is a Case rate ($11,107.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,255, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,576.69) for the length of stay and the standard reimbursement.","10602.78","10602.78","10602.78","1 through 10","2837","29764","case rate",""
"Cardiac Structural And Valvular Disorders,MODERATE","200","DRG","","","","","","","","inpatient","","","21619.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16445.58","","Standard inlier is a Case rate ($16,445.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,334.38) for the length of stay and the standard reimbursement.","16445.58","16445.58","16445.58","1 through 10","2837","29764","case rate",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","131.00","98.25","AETNA [1001]","HB CH AETNA HMO / PPO","76.37","58.3","","72.01","72.01","72.01","25","24.94","150.17","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","131.00","98.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.68","59.3","","74.42","74.42","145.29","17","14.19","102.77","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","102.77","78.45","","97.64","57.86","97.64","17","14.19","102.77","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","AETNA [1001]","HB CH AETNA HMO / PPO","1154.34","58.3","","1091.48","1091.48","1091.48","1 through 10","738.26","2048.05","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","800.35","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","800.86","799.86","802.92","1 through 10","738.26","2048.05","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","764.69","764.69","764.69","1 through 10","738.26","2048.05","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","MEDICARE [2001]","HB NWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","777.12","777.12","777.12","88","738.26","2048.05","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","761.58","761.58","761.58","1 through 10","738.26","2048.05","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","880.11","44.45","","1479.94","1479.94","1479.94","1 through 10","738.26","2048.05","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","769.08","761.58","769.48","1 through 10","738.26","2048.05","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","1980.00","1485.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1174.14","59.3","","1128.05","1128.05","1128.05","1 through 10","869.39","1707.2","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","1980.00","1485.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1553.31","78.45","","1479.94","877.03","1479.94","1 through 10","869.39","1707.2","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","16.53","114","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","58.50","68.56","1 through 10","11.02","94.14","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","both","","","73.00","54.75","TRICARE [160005]","HB NWH TRICARE","69.35","95","","11.11","11.11","11.11","1 through 10","9.04","69.35","percent of total billed charges",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","","","","inpatient","","","59362.69","44522.02","MEDICARE [2001]","HB NWH MEDICARE","20711.12","","Case rate ($20,711.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,275.94, add-ons for qualifying new technology services are included. If operating cost exceeds $66,418.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,524.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $19,128.39. The transfer operating threshold is the transfer adjustment factor * $21,275.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,582.72. The transfer capital threshold is the transfer adjustment factor * $1,582.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21711.06","21711.06","21711.06","1 through 10","20296.9","22495.4972","other","Inpatient Replacement Plans DRG"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","","","","inpatient","","","59362.69","44522.02","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20296.90","","Case rate ($20,711.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,275.94, add-ons for qualifying new technology services are included. If operating cost exceeds $66,418.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,524.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $19,128.39. The transfer operating threshold is the transfer adjustment factor * $21,275.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,582.72. The transfer capital threshold is the transfer adjustment factor * $1,582.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19411.22","19411.22","19411.22","1 through 10","20296.9","22495.4972","other","Inpatient DRG"
"Carotid Artery Stent Procedures With McC","034","MS-DRG","","","","","","","","inpatient","","","54090.90","40568.17","MEDICARE [2001]","HB NWH MEDICARE","33535.47","","Case rate ($33,535.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $34,450.02, add-ons for qualifying new technology services are included. If operating cost exceeds $79,592.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,504.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $30,972.71. The transfer operating threshold is the transfer adjustment factor * $34,450.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,562.75. The transfer capital threshold is the transfer adjustment factor * $2,562.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37181.13","37181.13","37181.13","1 through 10","32864.76","38455.3543","other","Inpatient Replacement Plans DRG"
"Carotid Artery Stent Procedures Without Cc/McC","036","MS-DRG","","","","","","","","inpatient","","","53876.98","40407.73","MEDICARE [2001]","HB NWH MEDICARE","16832.29","","Case rate ($16,832.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,291.32, add-ons for qualifying new technology services are included. If operating cost exceeds $62,433.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $15,545.97. The transfer operating threshold is the transfer adjustment factor * $17,291.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.31. The transfer capital threshold is the transfer adjustment factor * $1,286.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17495.43","17495.43","17526.88","1 through 10","16495.64","18127.5259","other","Inpatient Replacement Plans DRG"
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","AETNA [1001]","HB CH AETNA HMO / PPO","4022.70","58.3","","1530.90","1160.93","1884.08","89","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3657.00","53","","5253.92","5253.92","5253.92","1 through 10","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4002.00","58","","12181.47","12181.47","12181.47","1 through 10","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4312.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3067.05","44.45","","1910.74","891.94","1910.74","1 through 10","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","WELLPOINT [1015]","HB CH WELLPOINT","5375.79","77.91","","1829.79","1561.50","2617.12","88","3067.05","5375.79","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4091.70","59.3","","1359.46","1201.30","1689.00","61","3450","5413.05","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4091.70","59.3","","1718.92","1718.92","1718.92","1 through 10","3450","5413.05","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5413.05","78.45","","1910.74","1019.06","2344.84","74","3450","5413.05","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1530.90","1160.93","1884.08","89","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","5253.92","5253.92","5253.92","1 through 10","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","12181.47","12181.47","12181.47","1 through 10","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","1350.68","1350.68","1350.68","1 through 10","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1910.74","891.94","1910.74","1 through 10","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","1829.79","1561.50","2617.12","88","666.75","1168.65","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1359.46","1201.30","1689.00","61","750","1176.75","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","1718.92","1718.92","1718.92","1 through 10","750","1176.75","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1910.74","1019.06","2344.84","74","750","1176.75","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","208.00","156.00","AETNA [1001]","HB CH AETNA HMO / PPO","121.26","58.3","","114.53","114.53","114.53","1 through 10","24.75","197.6","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","208.00","156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","123.34","59.3","","118.37","118.37","129.81","1 through 10","26.04","163.18","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","208.00","156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","163.18","78.45","","155.30","92.03","202.00","1 through 10","26.04","163.18","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3758.57","3758.57","1 through 10","2529.37","14930.69","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","6551.07","6551.07","6551.07","1 through 10","2529.37","14930.69","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10840.09","53","","10540.64","10540.64","10540.64","1 through 10","2529.37","14930.69","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","MEDICARE [2001]","HB NWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","64","2529.37","14930.69","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","2894.20","2894.20","2894.20","1 through 10","2529.37","14930.69","per diem",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3743.49","3743.29","3743.69","1 through 10","2529.37","14930.69","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","20453.00","15339.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3746.35","3485.35","3751.19","11","2529.37","14930.69","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","20453.00","15339.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5944.02","5944.02","5944.02","1 through 10","2529.37","16045.38","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","20453.00","15339.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6247.54","6247.54","6247.54","1 through 10","2529.37","16045.38","other","Multiple Surgery"
"Cath TPA Injection Into Hematoma/Seroma/Collection Subcutaneous","PX-76002452","CDM","17999","CPT","0761","RC","","","","outpatient","","","388.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","194.39","50.1","","142.89","142.89","142.89","1 through 10","190.39","567.68","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","290.00","217.50","AETNA [1001]","HB CH AETNA HMO / PPO","169.07","58.3","","159.89","159.89","159.89","11","153.7","225.94","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","142.41","142.41","142.41","1 through 10","153.7","225.94","per diem",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","167.51","162.71","324.42","1 through 10","153.7","225.94","per diem",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","180.48","180.48","180.48","17","153.7","225.94","per diem",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","290.00","217.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","97.65","","Case rate ($97.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","282.00","282.00","282.00","1 through 10","97.65","227.51","other","ASC "
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","290.00","217.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","171.97","59.3","","165.25","165.25","165.25","1 through 10","97.65","227.51","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","290.00","217.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.51","78.45","","216.80","128.48","216.80","1 through 10","97.65","227.51","percent of total billed charges",""
"CATHETER ACUITY 8FR 54CM GUIDING BREAK AWAY OUTER MULTIPURPOSE CORONARY","SUP-ITM-10080591","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.00","263.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.03","53","","163.66","163.66","163.66","1 through 10","156.02","273.46","percent of total billed charges",""
"CATHETER ACUITY 8FR 54CM GUIDING BREAK AWAY OUTER MULTIPURPOSE CORONARY","SUP-ITM-10080591","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","219.38","62.5","","97.92","97.92","225.72","1 through 10","156.02","273.46","percent of total billed charges",""
"CATHETER ACUITY 8FR 54CM GUIDING BREAK AWAY OUTER MULTIPURPOSE CORONARY","SUP-ITM-10080591","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.00","263.25","WELLPOINT [1015]","HB CH WELLPOINT","273.46","77.91","","243.20","243.20","243.20","1 through 10","156.02","273.46","percent of total billed charges",""
"CATHETER ACUITY 8FR 54CM GUIDING BREAK AWAY OUTER MULTIPURPOSE CORONARY","SUP-ITM-10080591","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","275.36","78.45","","40.36","40.36","40.36","1 through 10","175.5","275.36","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","625.16","468.87","WELLPOINT [1015]","HB CH WELLPOINT","487.06","77.91","","582.67","582.67","582.67","1 through 10","277.88","487.06","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","625.16","468.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","490.44","78.45","","394.74","331.66","1115.07","1 through 10","312.58","490.44","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","5322.31","3991.73","WELLPOINT [1015]","HB CH WELLPOINT","4146.61","77.91","","582.67","582.67","582.67","1 through 10","2365.77","4146.61","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","5322.31","3991.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4175.35","78.45","","394.74","331.66","1115.07","1 through 10","2661.16","4175.35","percent of total billed charges",""
"Catheter Bladder Complicated","PX-76001259","CDM","51703","CPT","0761","RC","","","","outpatient","","","591.00","443.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","224.50","224.50","224.50","1 through 10","155.47","463.64","other","ASC "
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","188.11","188.11","188.11","1 through 10","121.77","263.01","percent of total billed charges",""
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","both","","","324.00","243.00","AETNA [1001]","HB CH AETNA HMO / PPO","188.89","58.3","","178.61","178.61","178.61","1 through 10","145.42","414.21","percent of total billed charges",""
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","both","","","324.00","243.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","89.45","89.45","89.45","1 through 10","145.42","414.21","per diem",""
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","outpatient","","","324.00","243.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","176.08","172.43","176.08","1 through 10","121.77","263.01","other","ASC "
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","AETNA [1001]","HB CH AETNA HMO / PPO","3302.70","58.3","","2190.90","412.50","9264.59","16","2518.09","4413.6","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3285.70","58","","1903.20","1903.20","3826.66","1 through 10","2518.09","4413.6","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3540.63","62.5","","2186.25","2186.25","2186.25","32","2518.09","4413.6","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4135.45","73","","5556.60","5556.60","5556.60","1 through 10","2518.09","4413.6","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","WELLPOINT [1015]","HB CH WELLPOINT","4413.60","77.91","","1955.15","885.83","3150.40","26","2518.09","4413.6","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5665.00","4248.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3359.35","59.3","","831.03","253.22","2394.88","18","2832.5","4444.19","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5665.00","4248.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4444.19","78.45","","2481.69","1563.74","8149.28","1 through 10","2832.5","4444.19","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1010.91","758.18","WELLPOINT [1015]","HB CH WELLPOINT","787.60","77.91","","582.67","582.67","582.67","1 through 10","449.35","787.6","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1010.91","758.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","793.06","78.45","","394.74","331.66","1115.07","1 through 10","505.46","793.06","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","921.42","691.06","WELLPOINT [1015]","HB CH WELLPOINT","717.88","77.91","","582.67","582.67","582.67","1 through 10","409.57","717.88","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","921.42","691.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","722.85","78.45","","394.74","331.66","1115.07","1 through 10","460.71","722.85","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1010.91","758.18","WELLPOINT [1015]","HB CH WELLPOINT","787.60","77.91","","582.67","582.67","582.67","1 through 10","449.35","787.6","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1010.91","758.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","793.06","78.45","","394.74","331.66","1115.07","1 through 10","505.46","793.06","percent of total billed charges",""
"CATHETER DILATION 7MM 4CM 21FR 5.8 75 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10065044","CDM","C1726","HCPCS","0272","RC","","","","both","","","944.61","708.46","WELLPOINT [1015]","HB CH WELLPOINT","735.95","77.91","","582.67","582.67","582.67","1 through 10","419.88","735.95","percent of total billed charges",""
"CATHETER DILATION 7MM 4CM 21FR 5.8 75 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10065044","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","944.61","708.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.05","78.45","","394.74","331.66","1115.07","1 through 10","472.31","741.05","percent of total billed charges",""
"CATHETER DRAINAGE 14FRX20CM MALECOT SILICONE WINGED","SUP-ITM-10078503","CDM","C1729","HCPCS","0272","RC","","","","both","","","305.40","229.05","AETNA [1001]","HB CH AETNA HMO / PPO","178.05","58.3","","34.87","34.02","34.87","1 through 10","135.75","237.94","percent of total billed charges",""
"CATHETER DRAINAGE 14FRX20CM MALECOT SILICONE WINGED","SUP-ITM-10078503","CDM","C1729","HCPCS","0272","RC","","","","both","","","305.40","229.05","WELLPOINT [1015]","HB CH WELLPOINT","237.94","77.91","","81.73","36.01","81.73","1 through 10","135.75","237.94","percent of total billed charges",""
"CATHETER DRAINAGE 14FRX20CM MALECOT SILICONE WINGED","SUP-ITM-10078503","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","305.40","229.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","239.59","78.45","","35.15","35.15","162.55","1 through 10","152.7","239.59","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1089.27","816.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","577.31","53","","163.66","163.66","163.66","1 through 10","484.18","848.65","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1089.27","816.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","680.79","62.5","","97.92","97.92","225.72","1 through 10","484.18","848.65","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1089.27","816.95","WELLPOINT [1015]","HB CH WELLPOINT","848.65","77.91","","243.20","243.20","243.20","1 through 10","484.18","848.65","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1089.27","816.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","854.53","78.45","","40.36","40.36","40.36","1 through 10","544.64","854.53","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","314.14","235.60","AETNA [1001]","HB CH AETNA HMO / PPO","183.14","58.3","","34.87","34.02","34.87","1 through 10","139.64","244.75","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","314.14","235.60","WELLPOINT [1015]","HB CH WELLPOINT","244.75","77.91","","81.73","36.01","81.73","1 through 10","139.64","244.75","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","314.14","235.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","246.44","78.45","","35.15","35.15","162.55","1 through 10","157.07","246.44","percent of total billed charges",""
"CATHETER ENDOFLIP 8CM LF NASAL TIP CT/5EA","SUP-ITM-10213494","CDM","C1726","HCPCS","0272","RC","","","","both","","","1345.20","1008.90","WELLPOINT [1015]","HB CH WELLPOINT","1048.05","77.91","","582.67","582.67","582.67","1 through 10","597.94","1048.05","percent of total billed charges",""
"CATHETER ENDOFLIP 8CM LF NASAL TIP CT/5EA","SUP-ITM-10213494","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1345.20","1008.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1055.31","78.45","","394.74","331.66","1115.07","1 through 10","672.6","1055.31","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X35MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310261","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1017.00","762.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","797.84","78.45","","166.06","166.06","166.06","1 through 10","508.5","797.84","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","981.00","735.75","WELLPOINT [1015]","HB CH WELLPOINT","764.30","77.91","","582.67","582.67","582.67","1 through 10","436.05","764.3","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","981.00","735.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","769.59","78.45","","394.74","331.66","1115.07","1 through 10","490.5","769.59","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1497.00","1122.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1174.40","78.45","","166.06","166.06","166.06","1 through 10","748.5","1174.4","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","739.80","554.85","WELLPOINT [1015]","HB CH WELLPOINT","576.38","77.91","","582.67","582.67","582.67","1 through 10","328.84","576.38","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","739.80","554.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","580.37","78.45","","394.74","331.66","1115.07","1 through 10","369.9","580.37","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","AETNA [1001]","HB CH AETNA HMO / PPO","50.28","58.3","","48.90","46.54","48.90","1 through 10","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","45.71","53","","91.65","91.65","91.65","1 through 10","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","50.03","58","","51.23","51.23","51.23","1 through 10","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","53.91","62.5","","65.12","36.89","65.12","1 through 10","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","62.96","73","","46.29","46.29","46.29","1 through 10","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","both","","","86.25","64.69","WELLPOINT [1015]","HB CH WELLPOINT","67.20","77.91","","64.65","45.40","120.92","18","38.34","67.2","percent of total billed charges",""
"CATHETER IMPRESS 4FR 10CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR CS/10EA","SUP-ITM-10115668","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","86.25","64.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","67.66","78.45","","276.77","63.10","312.43","11","43.13","67.66","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2191.61","1643.71","AETNA [1001]","HB CH AETNA HMO / PPO","1277.71","58.3","","1522.80","1522.80","1522.80","1 through 10","974.17","1707.48","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2191.61","1643.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1369.76","62.5","","415.49","415.49","415.49","1 through 10","974.17","1707.48","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2191.61","1643.71","WELLPOINT [1015]","HB CH WELLPOINT","1707.48","77.91","","511.31","511.31","511.31","1 through 10","974.17","1707.48","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","2191.61","1643.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1719.32","78.45","","499.10","499.10","5227.84","1 through 10","1095.81","1719.32","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","AETNA [1001]","HB CH AETNA HMO / PPO","2798.40","58.3","","1522.80","1522.80","1522.80","1 through 10","2133.6","3739.68","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3000.00","62.5","","415.49","415.49","415.49","1 through 10","2133.6","3739.68","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB CH WELLPOINT","3739.68","77.91","","511.31","511.31","511.31","1 through 10","2133.6","3739.68","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3765.60","78.45","","499.10","499.10","5227.84","1 through 10","2400","3765.6","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DIALYSIS DIALYSIS DOUBLE CUF","SUP-ITM-10000447","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","528.78","396.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","414.83","78.45","","680.39","680.39","680.39","1 through 10","264.39","414.83","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","448.05","336.04","WELLPOINT [1015]","HB CH WELLPOINT","349.08","77.91","","582.67","582.67","582.67","1 through 10","199.16","349.08","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.50","78.45","","394.74","331.66","1115.07","1 through 10","224.03","351.5","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","305.91","229.43","WELLPOINT [1015]","HB CH WELLPOINT","238.33","77.91","","352.06","352.06","352.06","1 through 10","135.98","238.33","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","305.91","229.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","239.99","78.45","","201.93","201.93","201.93","1 through 10","152.96","239.99","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","837.00","627.75","AETNA [1001]","HB CH AETNA HMO / PPO","487.97","58.3","","2190.90","412.50","9264.59","16","372.05","652.11","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","837.00","627.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","485.46","58","","1903.20","1903.20","3826.66","1 through 10","372.05","652.11","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","837.00","627.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","523.13","62.5","","2186.25","2186.25","2186.25","32","372.05","652.11","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","837.00","627.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","611.01","73","","5556.60","5556.60","5556.60","1 through 10","372.05","652.11","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","837.00","627.75","WELLPOINT [1015]","HB CH WELLPOINT","652.11","77.91","","1955.15","885.83","3150.40","26","372.05","652.11","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","837.00","627.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","496.34","59.3","","831.03","253.22","2394.88","18","418.5","656.63","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","837.00","627.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","656.63","78.45","","2481.69","1563.74","8149.28","1 through 10","418.5","656.63","percent of total billed charges",""
"CATHETER RELIEVA SPINPLUS 6X16MM BALLOON SINUPLASTY SYSTEM W/ IRRIGATION BX/5EA","SUP-ITM-10159436","CDM","C1726","HCPCS","0272","RC","","","","both","","","4095.00","3071.25","WELLPOINT [1015]","HB CH WELLPOINT","3190.41","77.91","","582.67","582.67","582.67","1 through 10","1820.23","3190.41","percent of total billed charges",""
"CATHETER RELIEVA SPINPLUS 6X16MM BALLOON SINUPLASTY SYSTEM W/ IRRIGATION BX/5EA","SUP-ITM-10159436","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3212.53","78.45","","394.74","331.66","1115.07","1 through 10","2047.5","3212.53","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","4900.00","3675.00","AETNA [1001]","HB CH AETNA HMO / PPO","2856.70","58.3","","2190.90","412.50","9264.59","16","2178.05","3817.59","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","4900.00","3675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2842.00","58","","1903.20","1903.20","3826.66","1 through 10","2178.05","3817.59","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","4900.00","3675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3062.50","62.5","","2186.25","2186.25","2186.25","32","2178.05","3817.59","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","4900.00","3675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3577.00","73","","5556.60","5556.60","5556.60","1 through 10","2178.05","3817.59","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","4900.00","3675.00","WELLPOINT [1015]","HB CH WELLPOINT","3817.59","77.91","","1955.15","885.83","3150.40","26","2178.05","3817.59","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4900.00","3675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2905.70","59.3","","831.03","253.22","2394.88","18","2450","3844.05","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4900.00","3675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3844.05","78.45","","2481.69","1563.74","8149.28","1 through 10","2450","3844.05","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","AETNA [1001]","HB CH AETNA HMO / PPO","96.89","58.3","","28.02","15.31","28.02","1 through 10","73.88","129.49","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.09","53","","79.50","79.50","79.50","1 through 10","73.88","129.49","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.88","44.45","","25.51","25.51","25.51","1 through 10","73.88","129.49","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","WELLPOINT [1015]","HB CH WELLPOINT","129.49","77.91","","135.65","59.07","274.09","13","73.88","129.49","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","166.20","124.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","98.56","59.3","","43.95","43.95","43.95","1 through 10","83.1","130.38","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","166.20","124.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","130.38","78.45","","57.66","15.03","149.03","11","83.1","130.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","both","","","149.40","112.05","AETNA [1001]","HB CH AETNA HMO / PPO","87.10","58.3","","28.02","15.31","28.02","1 through 10","66.41","116.4","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","both","","","149.40","112.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.18","53","","79.50","79.50","79.50","1 through 10","66.41","116.4","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","both","","","149.40","112.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.41","44.45","","25.51","25.51","25.51","1 through 10","66.41","116.4","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","both","","","149.40","112.05","WELLPOINT [1015]","HB CH WELLPOINT","116.40","77.91","","135.65","59.07","274.09","13","66.41","116.4","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","149.40","112.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.59","59.3","","43.95","43.95","43.95","1 through 10","74.7","117.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN FLEXIBLE TIP POLYURETHANE RADIOPAQUE MARKER","SUP-ITM-10047635","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","149.40","112.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.20","78.45","","57.66","15.03","149.03","11","74.7","117.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","AETNA [1001]","HB CH AETNA HMO / PPO","161.78","58.3","","28.02","15.31","28.02","1 through 10","123.35","216.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","147.08","53","","79.50","79.50","79.50","1 through 10","123.35","216.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.35","44.45","","25.51","25.51","25.51","1 through 10","123.35","216.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","WELLPOINT [1015]","HB CH WELLPOINT","216.20","77.91","","135.65","59.07","274.09","13","123.35","216.2","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","277.50","208.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","164.56","59.3","","43.95","43.95","43.95","1 through 10","138.75","217.7","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","277.50","208.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","217.70","78.45","","57.66","15.03","149.03","11","138.75","217.7","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","AETNA [1001]","HB CH AETNA HMO / PPO","12.73","58.3","","28.02","15.31","28.02","1 through 10","9.7","17.01","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","11.57","53","","79.50","79.50","79.50","1 through 10","9.7","17.01","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.70","44.45","","25.51","25.51","25.51","1 through 10","9.7","17.01","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","WELLPOINT [1015]","HB CH WELLPOINT","17.01","77.91","","135.65","59.07","274.09","13","9.7","17.01","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","21.83","16.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","12.95","59.3","","43.95","43.95","43.95","1 through 10","10.92","17.13","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","21.83","16.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.13","78.45","","57.66","15.03","149.03","11","10.92","17.13","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","AETNA [1001]","HB CH AETNA HMO / PPO","21.03","58.3","","28.02","15.31","28.02","1 through 10","16.04","28.11","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19.12","53","","79.50","79.50","79.50","1 through 10","16.04","28.11","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.04","44.45","","25.51","25.51","25.51","1 through 10","16.04","28.11","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","WELLPOINT [1015]","HB CH WELLPOINT","28.11","77.91","","135.65","59.07","274.09","13","16.04","28.11","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","36.08","27.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.40","59.3","","43.95","43.95","43.95","1 through 10","18.04","28.3","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","36.08","27.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.30","78.45","","57.66","15.03","149.03","11","18.04","28.3","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","AETNA [1001]","HB CH AETNA HMO / PPO","162.47","58.3","","28.02","15.31","28.02","1 through 10","123.87","217.12","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","147.70","53","","79.50","79.50","79.50","1 through 10","123.87","217.12","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.87","44.45","","25.51","25.51","25.51","1 through 10","123.87","217.12","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","WELLPOINT [1015]","HB CH WELLPOINT","217.12","77.91","","135.65","59.07","274.09","13","123.87","217.12","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","278.68","209.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","165.26","59.3","","43.95","43.95","43.95","1 through 10","139.34","218.62","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","278.68","209.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","218.62","78.45","","57.66","15.03","149.03","11","139.34","218.62","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","both","","","3.67","2.75","AETNA [1001]","HB CH AETNA HMO / PPO","2.14","58.3","","28.02","15.31","28.02","1 through 10","1.63","2.86","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","both","","","3.67","2.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1.95","53","","79.50","79.50","79.50","1 through 10","1.63","2.86","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","both","","","3.67","2.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1.63","44.45","","25.51","25.51","25.51","1 through 10","1.63","2.86","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","both","","","3.67","2.75","WELLPOINT [1015]","HB CH WELLPOINT","2.86","77.91","","135.65","59.07","274.09","13","1.63","2.86","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","3.67","2.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2.18","59.3","","43.95","43.95","43.95","1 through 10","1.84","2.88","percent of total billed charges",""
"CATHETER URETHRAL 12FR 16IN INTERMITTENT ALL PURPOSE RED CS/12EA","SUP-ITM-10020280","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","3.67","2.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2.88","78.45","","57.66","15.03","149.03","11","1.84","2.88","percent of total billed charges",""
"CATHETER VERSAFLEX Z 6FR ZNIS+8R PH-IMPEDANCE SINGLE CHANNEL CS/5EA","SUP-ITM-10130447","CDM","C1753","HCPCS","0272","RC","","","","both","","","649.20","486.90","AETNA [1001]","HB CH AETNA HMO / PPO","378.48","58.3","","1522.80","1522.80","1522.80","1 through 10","288.57","505.79","percent of total billed charges",""
"CATHETER VERSAFLEX Z 6FR ZNIS+8R PH-IMPEDANCE SINGLE CHANNEL CS/5EA","SUP-ITM-10130447","CDM","C1753","HCPCS","0272","RC","","","","both","","","649.20","486.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","405.75","62.5","","415.49","415.49","415.49","1 through 10","288.57","505.79","percent of total billed charges",""
"CATHETER VERSAFLEX Z 6FR ZNIS+8R PH-IMPEDANCE SINGLE CHANNEL CS/5EA","SUP-ITM-10130447","CDM","C1753","HCPCS","0272","RC","","","","both","","","649.20","486.90","WELLPOINT [1015]","HB CH WELLPOINT","505.79","77.91","","511.31","511.31","511.31","1 through 10","288.57","505.79","percent of total billed charges",""
"CATHETER VERSAFLEX Z 6FR ZNIS+8R PH-IMPEDANCE SINGLE CHANNEL CS/5EA","SUP-ITM-10130447","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","649.20","486.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","509.30","78.45","","499.10","499.10","5227.84","1 through 10","324.6","509.3","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6040.00","4530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4738.38","78.45","","7551.15","7551.15","7551.15","1 through 10","3020","4738.38","percent of total billed charges",""
"CATHETER X-FORCE 8MMX15CM DILATION BALLOON NEPHROSTOMY","SUP-ITM-10046600","CDM","C1726","HCPCS","0272","RC","","","","both","","","714.00","535.50","WELLPOINT [1015]","HB CH WELLPOINT","556.28","77.91","","582.67","582.67","582.67","1 through 10","317.37","556.28","percent of total billed charges",""
"CATHETER X-FORCE 8MMX15CM DILATION BALLOON NEPHROSTOMY","SUP-ITM-10046600","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","714.00","535.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","560.13","78.45","","394.74","331.66","1115.07","1 through 10","357","560.13","percent of total billed charges",""
"Catheter/Cann Artery Perc","PX-76001116","CDM","36620","CPT","0361","RC","","","","both","","","249.00","186.75","AETNA [1001]","HB CH AETNA HMO / PPO","145.17","58.3","","137.21","137.21","137.21","1 through 10","131.97","194","percent of total billed charges",""
"Catheter/Cann Artery Perc","PX-76001116","CDM","36620","CPT","0361","RC","","","","both","","","249.00","186.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","154.88","154.88","154.88","1 through 10","131.97","194","per diem",""
"Catheter/Cann Artery Perc","PX-76001116","CDM","36620","CPT","0361","RC","","","","both","","","249.00","186.75","WELLPOINT [1015]","HB CH WELLPOINT","194.00","77.91","","190.60","190.60","190.60","1 through 10","131.97","194","percent of total billed charges",""
"Cautery Cervix Electro or Thermal","PX-76001370","CDM","57510","CPT","0761","RC","","","","outpatient","","","4875.00","3656.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2442.38","50.1","","1952.28","1952.28","1952.28","1 through 10","1950","3824.44","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","496.00","372.00","WELLPOINT [1015]","HB CH WELLPOINT","386.43","77.91","","379.62","379.62","379.62","1 through 10","176.45","386.43","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","496.00","372.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","142.66","142.66","142.66","1 through 10","176.45","548.05","other","ASC "
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","496.00","372.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","142.86","142.86","142.86","1 through 10","176.45","548.05","other","ASC "
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.30","4.72","AETNA [1001]","HB CH AETNA HMO / PPO","3.67","58.3","","1.48","0.41","2.70","15","1.16","4.6","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.30","4.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","3.29","52.2","","0.85","0.79","1.09","72","1.03","3.29","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.30","4.72","AETNA [1001]","HB CH AETNA HMO / PPO","3.67","58.3","","1.48","0.41","2.70","15","1.16","4.6","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.30","4.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","3.29","52.2","","0.85","0.79","1.09","72","1.03","3.29","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","1 through 10","5.49","59.85","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","35.75","35.75","127.08","1 through 10","5.68","49.42","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","27.79","46.90","1 through 10","5.68","49.42","percent of total billed charges",""
"Cellulitis And Other Skin Infections,EXTREME","383","DRG","","","","","","","","inpatient","","","79404.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","41318.05","","Standard inlier is a Case rate ($41,318.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $51,108, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,864.92) for the length of stay and the standard reimbursement.","39439.95","39439.95","39439.95","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","20352.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22618.27","","Fee schedule rate ($22,618.27). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,617.07) multiplied by length of stay and the outlier percent (100%).","18094.62","16192.62","21590.16","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","20352.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9925.3818","","Fee schedule rate ($23,399.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9925.3818","23399.60","23399.60","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","20352.02","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","25739.31","","Fee schedule rate ($25,739.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25739.31","25739.31","25739.31","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","20352.02","","MASSHEALTH [3001]","HB NWH MEDICAID","8602.02","","Case rate ($9,267.31). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,697.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","6815.02","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","20352.02","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8602.02","","Case rate ($9,267.31). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,697.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9291.15","6398.92","12443.15","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10325.72","","Standard inlier is a Case rate ($10,325.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,465.78) for the length of stay and the standard reimbursement.","10325.71","9856.50","10325.71","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11091.88","","Standard inlier is a Case rate ($11,091.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,574.45) for the length of stay and the standard reimbursement.","10587.70","10587.70","11091.88","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10421.6001","","Fee schedule rate ($10,421.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10421.6001","8858.28","8858.28","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10917.82","","Fee schedule rate ($10,917.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10917.80","10917.80","10917.80","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","MASSHEALTH [3001]","HB NWH MEDICAID","4470.08","","Case rate ($4,815.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,245.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1475.61","1475.61","1475.61","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5028.36","","Fee schedule rate ($5,028.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3527.08","3527.08","3527.08","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","10717.70","","Fee schedule rate ($10,717.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9109.93","9109.93","9109.93","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","16114.23","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4470.08","","Case rate ($4,815.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,245.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1030.74","725.75","4828.19","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14152.51","","Standard inlier is a Case rate ($14,152.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,009.00) for the length of stay and the standard reimbursement.","13509.39","13509.39","13509.39","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15202.62","","Standard inlier is a Case rate ($15,202.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,157.95) for the length of stay and the standard reimbursement.","15202.61","15202.61","15202.61","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9925.3818","","Fee schedule rate ($11,850.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9925.3818","26326.77","30972.12","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10421.6001","","Fee schedule rate ($12,442.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10421.6001","14073.96","14073.96","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","15335.25","","Fee schedule rate ($15,335.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15335.25","15335.25","15335.25","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","MASSHEALTH [3001]","HB NWH MEDICAID","5924.31","","Case rate ($6,382.51). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,812.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6398.92","6398.92","7998.65","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12354.14","","Fee schedule rate ($12,354.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12354.14","12354.14","12354.14","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","5924.31","","Case rate ($6,382.51). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,812.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6398.92","6398.92","6398.92","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","22335.14","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5924.31","","Case rate ($6,382.51). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,812.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6398.92","418.14","7998.65","1 through 10","4274.14","91424.64","case rate",""
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26544.69","19908.52","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","12683.46","","Case rate ($12,314.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,649.86, add-ons for qualifying new technology services are included. If operating cost exceeds $57,792.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,373.01. The transfer operating threshold is the transfer adjustment factor * $12,649.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.03. The transfer capital threshold is the transfer adjustment factor * $941.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13153.50","13153.50","13153.50","1 through 10","12067.76","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26544.69","19908.52","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13539.59","","Case rate ($13,539.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,649.86, add-ons for qualifying new technology services are included. If operating cost exceeds $57,792.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,598.57. The transfer operating threshold is the transfer adjustment factor * $12,649.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.03. The transfer capital threshold is the transfer adjustment factor * $941.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12669.41","12669.41","12669.41","1 through 10","12067.76","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26544.69","19908.52","MEDICARE [2001]","HB NWH MEDICARE","13539.59","","Case rate ($13,539.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,649.86, add-ons for qualifying new technology services are included. If operating cost exceeds $57,792.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,598.57. The transfer operating threshold is the transfer adjustment factor * $12,649.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.03. The transfer capital threshold is the transfer adjustment factor * $941.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14047.50","12193.79","14047.50","17","12067.76","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26544.69","19908.52","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12067.76","","Case rate ($12,314.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,649.86, add-ons for qualifying new technology services are included. If operating cost exceeds $57,792.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,373.01. The transfer operating threshold is the transfer adjustment factor * $12,649.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.03. The transfer capital threshold is the transfer adjustment factor * $941.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12547.15","12529.35","12556.69","1 through 10","12067.76","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26544.69","19908.52","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12067.76","","Case rate ($12,314.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,649.86, add-ons for qualifying new technology services are included. If operating cost exceeds $57,792.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,373.01. The transfer operating threshold is the transfer adjustment factor * $12,649.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.03. The transfer capital threshold is the transfer adjustment factor * $941.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12530.15","12530.15","12530.15","1 through 10","12067.76","14589.64","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7771.78","","Case rate ($7,545.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,968.80. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7901.46","7893.66","7932.78","1 through 10","7394.51","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8296.38","","Case rate ($8,296.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,719.76. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7595.56","7595.56","7595.56","1 through 10","7394.51","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10066.03","10066.03","10066.03","1 through 10","7394.51","8939.79","case rate",""
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","MEDICARE [2001]","HB NWH MEDICARE","8296.38","","Case rate ($8,296.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,719.76. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8406.51","8134.98","8421.62","80","7394.51","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7394.51","","Case rate ($7,545.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,968.80. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7528.88","7507.76","7545.88","1 through 10","7394.51","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","7394.51","","Case rate ($7,545.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,968.80. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36.62","36.62","36.62","1 through 10","7394.51","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","20068.37","15051.28","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7394.51","","Case rate ($7,545.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,751.19, add-ons for qualifying new technology services are included. If operating cost exceeds $52,893.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,518.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,968.80. The transfer operating threshold is the transfer adjustment factor * $7,751.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.61. The transfer capital threshold is the transfer adjustment factor * $576.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7510.16","7507.78","7526.28","1 through 10","7394.51","8939.79","other","Inpatient DRG"
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","AETNA [1001]","HB CH AETNA HMO / PPO","4984.65","58.3","","464.71","67.87","1012.10","221","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4984.65","58.3","","293.04","293.04","293.04","11","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4531.50","53","","983.89","983.89","983.89","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4959.00","58","","677.18","677.18","677.18","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5343.75","62.5","","46.58","46.58","46.58","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6241.50","73","","747.15","747.15","747.15","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3800.48","44.45","","1141.67","481.21","1141.67","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3800.48","44.45","","76.54","76.54","76.54","1 through 10","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","WELLPOINT [1015]","HB CH WELLPOINT","6661.31","77.91","","273.64","94.28","1367.51","138","3800.48","6661.31","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5070.15","59.3","","720.78","230.14","2010.94","427","4275","6707.48","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5070.15","59.3","","344.45","344.45","344.45","1 through 10","4275","6707.48","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","6707.48","78.45","","1120.13","1120.13","1120.13","1 through 10","4275","6707.48","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6707.48","78.45","","456.17","105.33","1284.66","242","4275","6707.48","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","AETNA [1001]","HB CH AETNA HMO / PPO","91.82","58.3","","464.71","67.87","1012.10","221","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.82","58.3","","293.04","293.04","293.04","11","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","83.48","53","","983.89","983.89","983.89","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","91.35","58","","677.18","677.18","677.18","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","98.44","62.5","","46.58","46.58","46.58","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.98","73","","747.15","747.15","747.15","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","1141.67","481.21","1141.67","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","76.54","76.54","76.54","1 through 10","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB CH WELLPOINT","122.71","77.91","","273.64","94.28","1367.51","138","70.01","122.71","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.40","59.3","","720.78","230.14","2010.94","427","78.75","123.56","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","93.40","59.3","","344.45","344.45","344.45","1 through 10","78.75","123.56","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","1120.13","1120.13","1120.13","1 through 10","78.75","123.56","percent of total billed charges",""
"CEMENT BONE 1X40 STANDARD","SUP-ITM-10211828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","456.17","105.33","1284.66","242","78.75","123.56","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","464.71","67.87","1012.10","221","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.94","58.3","","293.04","293.04","293.04","11","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.04","53","","983.89","983.89","983.89","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","97.44","58","","677.18","677.18","677.18","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","105.00","62.5","","46.58","46.58","46.58","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","122.64","73","","747.15","747.15","747.15","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.68","44.45","","1141.67","481.21","1141.67","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.68","44.45","","76.54","76.54","76.54","1 through 10","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","WELLPOINT [1015]","HB CH WELLPOINT","130.89","77.91","","273.64","94.28","1367.51","138","74.68","130.89","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","720.78","230.14","2010.94","427","84","131.8","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","99.62","59.3","","344.45","344.45","344.45","1 through 10","84","131.8","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","1120.13","1120.13","1120.13","1 through 10","84","131.8","percent of total billed charges",""
"CEMENT BONE 1X40GM PALACOS R HIGH VISCOSITY","SUP-ITM-10282130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","456.17","105.33","1284.66","242","84","131.8","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","AETNA [1001]","HB CH AETNA HMO / PPO","169.65","58.3","","464.71","67.87","1012.10","221","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.65","58.3","","293.04","293.04","293.04","11","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.23","53","","983.89","983.89","983.89","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","168.78","58","","677.18","677.18","677.18","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","181.88","62.5","","46.58","46.58","46.58","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.43","73","","747.15","747.15","747.15","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.35","44.45","","1141.67","481.21","1141.67","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.35","44.45","","76.54","76.54","76.54","1 through 10","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","WELLPOINT [1015]","HB CH WELLPOINT","226.72","77.91","","273.64","94.28","1367.51","138","129.35","226.72","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.56","59.3","","720.78","230.14","2010.94","427","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","172.56","59.3","","344.45","344.45","344.45","1 through 10","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","228.29","78.45","","1120.13","1120.13","1120.13","1 through 10","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","228.29","78.45","","456.17","105.33","1284.66","242","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","AETNA [1001]","HB CH AETNA HMO / PPO","104.07","58.3","","464.71","67.87","1012.10","221","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.07","58.3","","293.04","293.04","293.04","11","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.61","53","","983.89","983.89","983.89","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","103.53","58","","677.18","677.18","677.18","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","111.56","62.5","","46.58","46.58","46.58","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","747.15","747.15","747.15","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","1141.67","481.21","1141.67","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","76.54","76.54","76.54","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB CH WELLPOINT","139.07","77.91","","273.64","94.28","1367.51","138","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.85","59.3","","720.78","230.14","2010.94","427","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","105.85","59.3","","344.45","344.45","344.45","1 through 10","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","1120.13","1120.13","1120.13","1 through 10","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","456.17","105.33","1284.66","242","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","AETNA [1001]","HB CH AETNA HMO / PPO","104.07","58.3","","464.71","67.87","1012.10","221","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.07","58.3","","293.04","293.04","293.04","11","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.61","53","","983.89","983.89","983.89","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","103.53","58","","677.18","677.18","677.18","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","111.56","62.5","","46.58","46.58","46.58","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","747.15","747.15","747.15","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","1141.67","481.21","1141.67","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","76.54","76.54","76.54","1 through 10","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB CH WELLPOINT","139.07","77.91","","273.64","94.28","1367.51","138","79.34","139.07","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.85","59.3","","720.78","230.14","2010.94","427","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","105.85","59.3","","344.45","344.45","344.45","1 through 10","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","1120.13","1120.13","1120.13","1 through 10","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","456.17","105.33","1284.66","242","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","464.71","67.87","1012.10","221","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.29","58.3","","293.04","293.04","293.04","11","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","333.90","53","","983.89","983.89","983.89","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","365.40","58","","677.18","677.18","677.18","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","393.75","62.5","","46.58","46.58","46.58","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","747.15","747.15","747.15","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","1141.67","481.21","1141.67","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","76.54","76.54","76.54","1 through 10","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB CH WELLPOINT","490.83","77.91","","273.64","94.28","1367.51","138","280.04","490.83","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","373.59","59.3","","720.78","230.14","2010.94","427","315","494.24","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","373.59","59.3","","344.45","344.45","344.45","1 through 10","315","494.24","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","1120.13","1120.13","1120.13","1 through 10","315","494.24","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX WITH GENTAMICIN P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL","SUP-ITM-10135423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","456.17","105.33","1284.66","242","315","494.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","464.71","67.87","1012.10","221","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","293.04","293.04","293.04","11","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","983.89","983.89","983.89","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","104.40","58","","677.18","677.18","677.18","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.50","62.5","","46.58","46.58","46.58","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","747.15","747.15","747.15","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","1141.67","481.21","1141.67","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","76.54","76.54","76.54","1 through 10","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","273.64","94.28","1367.51","138","80.01","140.24","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","720.78","230.14","2010.94","427","90","141.21","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","106.74","59.3","","344.45","344.45","344.45","1 through 10","90","141.21","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","1120.13","1120.13","1120.13","1 through 10","90","141.21","percent of total billed charges",""
"CEMENT BONE 40GRAM SMARTSET HV MULTIPLES OF 20S","SUP-ITM-10015447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","456.17","105.33","1284.66","242","90","141.21","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","AETNA [1001]","HB CH AETNA HMO / PPO","498.29","58.3","","464.71","67.87","1012.10","221","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.29","58.3","","293.04","293.04","293.04","11","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","452.99","53","","983.89","983.89","983.89","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.73","58","","677.18","677.18","677.18","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","534.19","62.5","","46.58","46.58","46.58","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","623.93","73","","747.15","747.15","747.15","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.91","44.45","","1141.67","481.21","1141.67","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.91","44.45","","76.54","76.54","76.54","1 through 10","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","WELLPOINT [1015]","HB CH WELLPOINT","665.90","77.91","","273.64","94.28","1367.51","138","379.91","665.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","506.84","59.3","","720.78","230.14","2010.94","427","427.35","670.51","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","506.84","59.3","","344.45","344.45","344.45","1 through 10","427.35","670.51","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","670.51","78.45","","1120.13","1120.13","1120.13","1 through 10","427.35","670.51","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.51","78.45","","456.17","105.33","1284.66","242","427.35","670.51","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","AETNA [1001]","HB CH AETNA HMO / PPO","342.80","58.3","","464.71","67.87","1012.10","221","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","342.80","58.3","","293.04","293.04","293.04","11","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","311.64","53","","983.89","983.89","983.89","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","341.04","58","","677.18","677.18","677.18","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","367.50","62.5","","46.58","46.58","46.58","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","429.24","73","","747.15","747.15","747.15","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.37","44.45","","1141.67","481.21","1141.67","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.37","44.45","","76.54","76.54","76.54","1 through 10","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","WELLPOINT [1015]","HB CH WELLPOINT","458.11","77.91","","273.64","94.28","1367.51","138","261.37","458.11","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","348.68","59.3","","720.78","230.14","2010.94","427","294","461.29","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","348.68","59.3","","344.45","344.45","344.45","1 through 10","294","461.29","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","461.29","78.45","","1120.13","1120.13","1120.13","1 through 10","294","461.29","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","461.29","78.45","","456.17","105.33","1284.66","242","294","461.29","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","5990.92","4687.96","5990.92","1 through 10","2125.14","3888.77","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","3888.77","other","Multiple Surgery"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","2125.14","3888.77","per diem",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1702.00","1702.00","1702.00","1 through 10","2125.14","3888.77","per diem",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3899.16","3899.16","1 through 10","1873.9","3628.31","other","ASC "
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3823.55","3823.55","3904.56","1 through 10","1873.9","3628.31","other","ASC "
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","4845.05","4845.05","4845.05","1 through 10","1873.9","3628.31","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","4589.74","4589.74","4589.74","1 through 10","1873.9","3628.31","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","355.00","266.25","AETNA [1001]","HB CH AETNA HMO / PPO","206.97","58.3","","121.91","121.91","121.91","1 through 10","18.27","337.25","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.52","59.3","","125.99","125.99","125.99","1 through 10","14.12","278.5","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.50","78.45","","165.29","97.95","215.00","1 through 10","14.12","278.5","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","93.00","69.75","AETNA [1001]","HB CH AETNA HMO / PPO","54.22","58.3","","51.03","51.03","102.06","1 through 10","10.53","88.35","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.34","44.45","","41.00","41.00","41.00","1 through 10","10.53","88.35","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","52.74","12","11.07","72.96","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","41.00","69.19","1 through 10","11.07","72.96","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","AETNA [1001]","HB CH AETNA HMO / PPO","5713.40","58.3","","2190.90","412.50","9264.59","16","4356.1","7635.18","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5684.00","58","","1903.20","1903.20","3826.66","1 through 10","4356.1","7635.18","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6125.00","62.5","","2186.25","2186.25","2186.25","32","4356.1","7635.18","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7154.00","73","","5556.60","5556.60","5556.60","1 through 10","4356.1","7635.18","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","WELLPOINT [1015]","HB CH WELLPOINT","7635.18","77.91","","1955.15","885.83","3150.40","26","4356.1","7635.18","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5811.40","59.3","","831.03","253.22","2394.88","18","4900","7688.1","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7688.10","78.45","","2481.69","1563.74","8149.28","1 through 10","4900","7688.1","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","both","","","10600.00","7950.00","AETNA [1001]","HB CH AETNA HMO / PPO","6179.80","58.3","","2190.90","412.50","9264.59","16","4711.7","8258.46","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","both","","","10600.00","7950.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6148.00","58","","1903.20","1903.20","3826.66","1 through 10","4711.7","8258.46","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","both","","","10600.00","7950.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6625.00","62.5","","2186.25","2186.25","2186.25","32","4711.7","8258.46","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","both","","","10600.00","7950.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7738.00","73","","5556.60","5556.60","5556.60","1 through 10","4711.7","8258.46","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","both","","","10600.00","7950.00","WELLPOINT [1015]","HB CH WELLPOINT","8258.46","77.91","","1955.15","885.83","3150.40","26","4711.7","8258.46","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10600.00","7950.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6285.80","59.3","","831.03","253.22","2394.88","18","5300","8315.7","percent of total billed charges",""
"CERVICAL DISC MED 4MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287028","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10600.00","7950.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8315.70","78.45","","2481.69","1563.74","8149.28","1 through 10","5300","8315.7","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 16.0MM LEVEL 1 REFLEX HYBRID CURVED","SUP-ITM-10029672","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 26MM LEVEL 1 HALLMARK ACPS","SUP-ITM-10109968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","464.71","67.87","1012.10","221","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","293.04","293.04","293.04","11","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","983.89","983.89","983.89","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.60","58","","677.18","677.18","677.18","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.25","62.5","","46.58","46.58","46.58","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","747.15","747.15","747.15","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","1141.67","481.21","1141.67","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","76.54","76.54","76.54","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","273.64","94.28","1367.51","138","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","720.78","230.14","2010.94","427","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1049.61","59.3","","344.45","344.45","344.45","1 through 10","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","1120.13","1120.13","1120.13","1 through 10","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","456.17","105.33","1284.66","242","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","464.71","67.87","1012.10","221","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","293.04","293.04","293.04","11","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","983.89","983.89","983.89","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.60","58","","677.18","677.18","677.18","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.25","62.5","","46.58","46.58","46.58","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","747.15","747.15","747.15","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","1141.67","481.21","1141.67","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","76.54","76.54","76.54","1 through 10","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","273.64","94.28","1367.51","138","786.77","1379.01","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","720.78","230.14","2010.94","427","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1049.61","59.3","","344.45","344.45","344.45","1 through 10","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","1120.13","1120.13","1120.13","1 through 10","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","456.17","105.33","1284.66","242","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","464.71","67.87","1012.10","221","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","293.04","293.04","293.04","11","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","983.89","983.89","983.89","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","677.18","677.18","677.18","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","46.58","46.58","46.58","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","747.15","747.15","747.15","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","1141.67","481.21","1141.67","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","76.54","76.54","76.54","1 through 10","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","273.64","94.28","1367.51","138","900.11","1577.68","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","720.78","230.14","2010.94","427","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1200.83","59.3","","344.45","344.45","344.45","1 through 10","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 54MM LEVEL 3 REFLEX HYBRID CURVED","SUP-ITM-10047407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","456.17","105.33","1284.66","242","1012.5","1588.61","percent of total billed charges",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","26290.52","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25957.96","25957.96","25957.96","1 through 10","25014.28","28650.4108","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","25524.78","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24983.90","24983.90","24983.90","1 through 10","25014.28","28650.4108","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","HUMANA [1012]","HB NWH MEDICARE","25524.78","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24714.01","24714.01","24714.01","1 through 10","25014.28","28650.4108","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","MEDICARE [2001]","HB NWH MEDICARE","25524.78","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27651.37","15392.42","27701.08","23","25014.28","28650.4108","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","25014.28","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24735.52","24735.52","24735.52","1 through 10","25014.28","28650.4108","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","68993.44","51745.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","25014.28","","Case rate ($25,524.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,220.89, add-ons for qualifying new technology services are included. If operating cost exceeds $71,363.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,892.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $23,574.21. The transfer operating threshold is the transfer adjustment factor * $26,220.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,950.58. The transfer capital threshold is the transfer adjustment factor * $1,950.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24713.32","24713.32","24713.32","1 through 10","25014.28","28650.4108","other","Inpatient DRG"
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","74752.90","56064.67","MEDICARE [2001]","HB NWH MEDICARE","41835.50","","Case rate ($41,835.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $42,976.42, add-ons for qualifying new technology services are included. If operating cost exceeds $88,118.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,139.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $38,638.47. The transfer operating threshold is the transfer adjustment factor * $42,976.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,197.03. The transfer capital threshold is the transfer adjustment factor * $3,197.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46442.25","46442.25","46442.25","1 through 10","40998.79","48033.8397","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","74752.90","56064.67","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","40998.79","","Case rate ($41,835.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $42,976.42, add-ons for qualifying new technology services are included. If operating cost exceeds $88,118.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,139.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $38,638.47. The transfer operating threshold is the transfer adjustment factor * $42,976.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,197.03. The transfer capital threshold is the transfer adjustment factor * $3,197.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41418.48","41418.48","41418.48","1 through 10","40998.79","48033.8397","other","Inpatient DRG"
"Cervical Spinal Fusion Without Cc/McC","473","MS-DRG","","","","","","","","inpatient","","","47829.22","35871.91","MEDICARE [2001]","HB NWH MEDICARE","23256.31","","Case rate ($23,256.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,728.07, add-ons for qualifying new technology services are included. If operating cost exceeds $66,870.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,558.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $21,639.96. The transfer operating threshold is the transfer adjustment factor * $21,728.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,616.36. The transfer capital threshold is the transfer adjustment factor * $1,616.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22635.50","22594.88","22635.50","1 through 10","20728.21","23411.2186","other","Inpatient DRG"
"Cervical Spinal Fusion Without Cc/McC","473","MS-DRG","","","","","","","","inpatient","","","47829.22","35871.91","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20728.21","","Case rate ($21,151.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,728.07, add-ons for qualifying new technology services are included. If operating cost exceeds $66,870.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,558.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $19,534.89. The transfer operating threshold is the transfer adjustment factor * $21,728.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,616.36. The transfer capital threshold is the transfer adjustment factor * $1,616.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20215.56","20215.56","20215.56","1 through 10","20728.21","23411.2186","other","Inpatient DRG"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","113.13","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.03","113.03","113.03","1 through 10","101.76","254.1","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.09","108.09","108.09","1 through 10","101.76","254.1","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","121.73","63.4","","101.48","101.48","101.48","1 through 10","101.76","254.1","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","MEDICARE [2001]","HB NWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","97.29","109.85","15","101.76","254.1","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","107.65","107.65","1 through 10","101.76","254.1","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.66","107.66","107.66","1 through 10","101.76","254.1","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","outpatient","","","192.00","144.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.86","59.3","","328.74","328.74","328.74","1 through 10","62.13","150.62","percent of total billed charges",""
"Cesarean Delivery Only","PX-72000022","CDM","59514","CPT","0720","RC","","","","outpatient","","","10279.00","7709.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1536.53","","Case rate ($1,536.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2175.73","2175.73","2175.73","1 through 10","1536.53","8063.88","other","ASC "
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","","","","inpatient","","","27402.77","20552.08","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10174.61","10174.61","10174.61","1 through 10","9000.94","10709.787","case rate",""
"Cesarean Section With Sterilization With McC","783","MS-DRG","","","","","","","","inpatient","","","33282.46","24961.84","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10174.61","10174.61","10174.61","1 through 10","18216.5269","21908.94","case rate",""
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","27267.89","20450.92","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8634.72","8634.72","8634.72","1 through 10","8132.35","8638.0415","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","29634.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25632.88","","Standard inlier is a Case rate ($25,632.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,944, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,638.69) for the length of stay and the standard reimbursement.","24468.08","24468.08","25632.88","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","29634.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27534.83","","Standard inlier is a Case rate ($27,534.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,944, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,908.45) for the length of stay and the standard reimbursement.","27534.83","27534.83","27534.83","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","27116.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15701.86","","Standard inlier is a Case rate ($15,701.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,228.94) for the length of stay and the standard reimbursement.","15701.85","15701.85","15875.74","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","27116.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16866.93","","Standard inlier is a Case rate ($16,866.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,394.19) for the length of stay and the standard reimbursement.","16866.92","16100.24","16866.92","26","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","27116.42","","MASSHEALTH [3001]","HB NWH MEDICAID","7994.28","","Case rate ($8,612.57). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,042.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8874.09","8874.09","8874.09","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","27402.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18136.20","","Standard inlier is a Case rate ($18,136.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,255, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,574.50) for the length of stay and the standard reimbursement.","18136.19","18136.19","18136.19","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","27402.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19481.89","","Standard inlier is a Case rate ($19,481.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,255, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,765.37) for the length of stay and the standard reimbursement.","19481.89","18596.35","19481.89","1 through 10","7994.28","56981.51","case rate",""
"Cesarean Section Without Sterilization With Cc","772","TRIS-DRG","","","","","","","","inpatient","","","20206.07","","TRICARE [160005]","HB NWH TRICARE","6773.14","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($9,496.34). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,317.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,426.48), capped at $8,562.98. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,317.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","6636.50","6636.50","6636.50","1 through 10","6773.14","6773.14","other","Inpatient DRGs"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","32168.13","24126.10","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11330.76","11330.76","11330.76","1 through 10","9482.35","11463.95","case rate",""
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","34318.78","25739.08","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11330.76","8874.09","11330.76","1 through 10","14005.32","16932.12","case rate",""
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","30366.73","22775.05","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8874.09","8874.09","11330.76","1 through 10","8140.84","9842.08","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","50826.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25483.41","","Standard inlier is a Case rate ($25,483.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,617.26) for the length of stay and the standard reimbursement.","42821.71","42821.71","42821.71","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","50826.93","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6873.97","","Fee schedule rate ($6,873.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20141.68","20141.68","20141.68","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23723.17","","Standard inlier is a Case rate ($23,723.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,367.60) for the length of stay and the standard reimbursement.","23723.16","22645.14","23723.16","17","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25483.41","","Standard inlier is a Case rate ($25,483.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,617.26) for the length of stay and the standard reimbursement.","25483.41","24325.07","25483.41","44","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14379.0036","","Fee schedule rate ($21,636.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14379.0036","21636.90","21636.90","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","15097.8802","","Fee schedule rate ($22,718.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15097.8802","22718.64","22718.64","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","23800.37","","Fee schedule rate ($23,800.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23800.37","23800.36","23800.37","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","20850.01","","Fee schedule rate ($20,850.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20850.01","20850.01","20850.01","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","13631.85","","Case rate ($14,686.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,116.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14723.94","14723.94","14723.94","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","35702.64","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","13631.85","","Case rate ($14,686.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,116.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3539.41","3539.41","3539.41","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15407.68","","Standard inlier is a Case rate ($15,407.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,187.18) for the length of stay and the standard reimbursement.","15407.67","14707.52","15407.67","44","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16550.92","","Standard inlier is a Case rate ($16,550.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,349.33) for the length of stay and the standard reimbursement.","16550.91","15798.60","16550.91","128","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14379.0036","","Fee schedule rate ($14,379.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14379.0036","14379.00","14379.00","30","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","15097.8802","","Fee schedule rate ($15,097.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15097.8802","15097.88","15816.76","20","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","15816.76","","Fee schedule rate ($15,816.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15816.76","15206.76","15816.76","11","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","15097.88","","Fee schedule rate ($15,097.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15097.88","15097.88","15097.88","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","MASSHEALTH [3001]","HB NWH MEDICAID","8215.90","","Case rate ($8,851.33). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,281.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8874.09","8874.09","8874.09","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","5007.84","","Fee schedule rate ($5,007.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5007.80","5007.80","5007.80","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5891.53","","Fee schedule rate ($5,891.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5891.53","5719.97","5891.53","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","28019.13","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12557.51","","Fee schedule rate ($12,557.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12557.51","12557.51","12557.51","24","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18768.68","","Standard inlier is a Case rate ($18,768.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,664.29) for the length of stay and the standard reimbursement.","18768.68","17915.80","18768.68","52","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","20161.31","","Standard inlier is a Case rate ($20,161.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,861.81) for the length of stay and the standard reimbursement.","19244.88","19244.88","19244.88","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20161.31","","Standard inlier is a Case rate ($20,161.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,861.81) for the length of stay and the standard reimbursement.","20161.31","19244.88","20161.31","149","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14379.0036","","Fee schedule rate ($16,501.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14379.0036","15865.44","16501.26","26","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","15097.8802","","Fee schedule rate ($17,326.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15097.8802","17326.24","18151.22","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","18151.22","","Fee schedule rate ($18,151.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18151.22","17451.21","21361.09","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","MASSHEALTH [3001]","HB NWH MEDICAID","10490.35","","Case rate ($11,301.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,731.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11330.75","11330.75","11330.75","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","5842.92","","Fee schedule rate ($5,842.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5842.88","5842.88","5842.88","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6873.97","","Fee schedule rate ($6,873.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6873.97","6873.97","6873.97","12","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","7217.36","","Fee schedule rate ($7,217.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6873.97","6873.97","6873.97","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14651.54","","Fee schedule rate ($14,651.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14651.54","14224.93","14651.54","1 through 10","5007.84","35700.56","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","32820.98","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","15816.7568","","Fee schedule rate ($18,151.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15816.7568","17451.21","17451.21","1 through 10","5007.84","35700.56","case rate",""
"Change G-TB to G-J TB Perc Fluoro","PX-75000301","CDM","49446","CPT","0361","RC","","","","both","","","3406.00","2554.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Change G-TB to G-J TB Perc Fluoro","PX-75000301","CDM","49446","CPT","0361","RC","","","","outpatient","","","3406.00","2554.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2401.96","1 through 10","1335.02","2672.01","other","ASC "
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","261.00","195.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","128.07","49.07","","1257.55","1257.55","1257.55","1 through 10","128.07","7178","percent of total billed charges",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","297.46","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","297.90","297.90","297.90","1 through 10","231.42","516.54","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.21","284.21","284.21","1 through 10","231.42","516.54","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","ELDER SERVICES [1037]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.05","264.35","283.05","1 through 10","231.42","516.54","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","599.38","299.69","599.38","1 through 10","231.42","516.54","other","Multiple Surgery"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","MEDICARE [2001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","95","231.42","516.54","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","262.00","270.00","1 through 10","231.42","516.54","per diem",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.06","264.35","288.83","1 through 10","231.42","516.54","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","WELLPOINT [1015]","HB CH WELLPOINT","516.54","77.91","","508.00","508.00","508.00","1 through 10","231.42","516.54","percent of total billed charges",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","382.14","374.20","382.14","15","231.42","774.58","other","ASC "
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","382.67","374.73","382.67","20","231.42","774.58","other","ASC "
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","571.61","571.61","571.61","1 through 10","231.42","774.58","other","Multiple Surgery"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","520.12","78.45","","293.86","293.86","495.88","1 through 10","231.42","774.58","percent of total billed charges",""
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4391.00","3293.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2503.98","2503.98","2503.98","1 through 10","1565.78","3421.03","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4391.00","3293.25","ELDER SERVICES [1037]","HB NWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1192.04","1192.04","1192.04","1 through 10","1565.78","3421.03","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4391.00","3293.25","MEDICARE [2001]","HB NWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","1565.78","3421.03","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","715.00","536.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","521.95","73","","543.69","543.69","543.69","1 through 10","80.29","557.06","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","780.00","585.00","MEDICARE [2001]","HB NWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","369.63","393.90","1 through 10","374.21","728.13","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","374.79","14","247.48","529.79","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","661.00","661.00","661.00","1 through 10","247.48","529.79","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","247.48","529.79","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","727.59","661.01","727.59","1 through 10","247.48","529.79","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","661.00","616.23","962.70","1 through 10","247.48","529.79","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","247.48","529.79","per diem",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($256). Procedure 2, Per diem ($128). Procedures 3 - 9999, Per diem ($64).","256.00","256.00","256.00","1 through 10","247.48","529.79","per diem",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","16","247.48","529.79","per diem",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","247.48","529.79","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","511.55","520.60","13","247.48","529.79","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","400.18","408.67","50","247.48","970.06","other","ASC "
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","400.74","409.23","91","247.48","970.06","other","ASC "
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","387.35","387.35","387.35","19","247.48","970.06","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","1744.74","54","247.48","970.06","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","611.28","250.29","611.28","1 through 10","247.48","970.06","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","533.46","78.45","","661.00","508.18","661.00","21","247.48","970.06","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","53.31","53.31","53.31","1 through 10","13.84","114","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","1 through 10","11.02","94.14","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","53.31","89.95","1 through 10","11.02","94.14","percent of total billed charges",""
"Chemistry Unlstd Proc","PX-30001386","CDM","84999","CPT","0301","RC","","","","outpatient","","","7631.00","5723.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5986.52","78.45","","38.44","38.44","38.44","1 through 10","4.28","5986.52","percent of total billed charges",""
"Chemistry Unlstd Proc","PX-30003529","CDM","84999","CPT","0301","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","38.44","38.44","38.44","1 through 10","4.28","200.05","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","both","","","2325.00","1743.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","388.57","388.57","388.57","1 through 10","374.21","1811.41","other","OPPS APC"
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","both","","","2325.00","1743.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","388.57","388.57","388.57","1 through 10","374.21","1811.41","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","MEDICARE [2001]","HB NWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","393.90","393.90","116","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.59","73","","766.48","766.47","766.48","14","374.21","1121.8","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","386.02","362.24","388.57","1 through 10","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","387.60","363.72","387.60","1 through 10","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","WELLPOINT [1015]","HB CH WELLPOINT","843.77","77.91","","1082.85","829.34","1082.85","1 through 10","374.21","1121.8","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1083.00","812.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","642.22","59.3","","617.06","547.29","1554.70","1 through 10","476.2","1250.1","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1083.00","812.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.61","78.45","","847.84","809.55","1030.53","1 through 10","476.2","1250.1","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","50","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","75.56","75.56","75.56","1 through 10","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","WELLPOINT [1015]","HB CH WELLPOINT","246.97","77.91","","242.58","242.58","242.58","1 through 10","80.29","246.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","317.00","237.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","187.98","59.3","","180.49","180.49","180.49","1 through 10","98.67","248.69","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.69","78.45","","175.67","175.67","236.79","1 through 10","98.67","248.69","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","both","","","2325.00","1743.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","388.57","388.57","388.57","1 through 10","374.21","1811.41","other","OPPS APC"
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","both","","","2682.00","2011.50","AETNA [1001]","HB CH AETNA HMO / PPO","1563.61","58.3","","1735.30","1735.30","1735.30","1 through 10","598.81","2089.55","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","4775.00","3581.25","AETNA [1001]","HB CH AETNA HMO / PPO","2783.83","58.3","","1692.50","1692.50","1692.50","1 through 10","979.79","3720.2","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","outpatient","","","4775.00","3581.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2831.58","59.3","","3498.42","1749.21","3498.42","1 through 10","979.79","4472.66","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","outpatient","","","4775.00","3581.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3745.99","78.45","","1359.97","1359.97","1359.97","1 through 10","979.79","4472.66","percent of total billed charges",""
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","both","","","4775.00","3581.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2168.25","2161.25","2168.25","1 through 10","1330.22","5717.07","other","OPPS APC"
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","both","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2066.73","2066.73","2066.73","1 through 10","1330.22","5717.07","other","OPPS APC"
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1680.68","","Case rate ($1,680.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1188.24","1188.24","1213.45","1 through 10","1680.68","8319.15","other","ASC "
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1680.68","","Case rate ($1,680.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2430.26","1215.13","2430.26","1 through 10","1680.68","8319.15","other","ASC "
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","29105.95","21829.46","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","22012.01","","Case rate ($22,461.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $23,073.78, add-ons for qualifying new technology services are included. If operating cost exceeds $68,216.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,658.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $20,744.76. The transfer operating threshold is the transfer adjustment factor * $23,073.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,716.46. The transfer capital threshold is the transfer adjustment factor * $1,716.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21775.00","21775.00","21775.00","1 through 10","22012.01","26612.01","other","Inpatient DRG"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","626.00","469.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.22","59.3","","963.24","963.24","963.24","1 through 10","98.67","491.1","percent of total billed charges",""
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","22238.42","16678.81","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6425.17","","Case rate ($6,238.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,408.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,550.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,418.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,761.32. The transfer operating threshold is the transfer adjustment factor * $6,408.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.70. The transfer capital threshold is the transfer adjustment factor * $476.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6434.51","6434.51","6434.51","1 through 10","6113.27","7054.8126","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","22238.42","16678.81","MEDICARE [2001]","HB NWH MEDICARE","6858.87","","Case rate ($6,858.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,408.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,550.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,418.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,382.16. The transfer operating threshold is the transfer adjustment factor * $6,408.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.70. The transfer capital threshold is the transfer adjustment factor * $476.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6808.81","6808.72","6821.05","1 through 10","6113.27","7054.8126","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","22238.42","16678.81","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6113.27","","Case rate ($6,238.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,408.15, add-ons for qualifying new technology services are included. If operating cost exceeds $51,550.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,418.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,761.32. The transfer operating threshold is the transfer adjustment factor * $6,408.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.70. The transfer capital threshold is the transfer adjustment factor * $476.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6090.72","6090.72","6090.72","1 through 10","6113.27","7054.8126","other","Inpatient DRG"
"Chest Pain,MODERATE","203","DRG","","","","","","","","inpatient","","","28570.75","","MASSHEALTH [3001]","HB NWH MEDICAID","4371.83","","Case rate ($4,709.96). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,139.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4722.07","4722.07","4722.07","1 through 10","3336.85","15895.92","case rate",""
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","both","","","347.00","260.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","153.08","153.08","153.08","1 through 10","67.25","414.21","other","Tricare OPPS"
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","both","","","347.00","260.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","337.00","337.00","337.00","1 through 10","67.25","414.21","other","OPPS APC"
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","both","","","401.22","300.91","AETNA [1001]","HB CH AETNA HMO / PPO","233.91","58.3","","2190.90","412.50","9264.59","16","178.34","312.59","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","both","","","401.22","300.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","232.71","58","","1903.20","1903.20","3826.66","1 through 10","178.34","312.59","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","both","","","401.22","300.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","250.76","62.5","","2186.25","2186.25","2186.25","32","178.34","312.59","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","both","","","401.22","300.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","292.89","73","","5556.60","5556.60","5556.60","1 through 10","178.34","312.59","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","both","","","401.22","300.91","WELLPOINT [1015]","HB CH WELLPOINT","312.59","77.91","","1955.15","885.83","3150.40","26","178.34","312.59","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","401.22","300.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.92","59.3","","831.03","253.22","2394.88","18","200.61","314.76","percent of total billed charges",""
"CHIP PRESERVON .1 4MM GRAFT BONE READIGRAFT CANCELLOUS IMPLANTABLE","SUP-ITM-10117586","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","401.22","300.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.76","78.45","","2481.69","1563.74","8149.28","1 through 10","200.61","314.76","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","outpatient","","","47.00","35.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.87","59.3","","26.96","26.96","26.96","1 through 10","5.19","36.87","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","outpatient","","","47.00","35.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.87","78.45","","46.00","46.00","46.00","1 through 10","5.19","36.87","percent of total billed charges",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","","","","inpatient","","","76250.60","57187.95","MEDICARE [2001]","HB NWH MEDICARE","19687.81","","Case rate ($19,687.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,394.06, add-ons for qualifying new technology services are included. If operating cost exceeds $63,536.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,310.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,319.47. The transfer operating threshold is the transfer adjustment factor * $18,394.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,368.34. The transfer capital threshold is the transfer adjustment factor * $1,368.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16781.61","16781.61","16781.61","1 through 10","17547.63","19687.81","other","Inpatient DRG"
"Cholecystectomy Except By Laparoscope Without C.D.E. With McC","414","MS-DRG","","","","","","","","inpatient","","","144509.45","108382.09","MEDICARE [2001]","HB NWH MEDICARE","30866.10","","Case rate ($30,866.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,707.87, add-ons for qualifying new technology services are included. If operating cost exceeds $76,850.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,300.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $28,507.35. The transfer operating threshold is the transfer adjustment factor * $31,707.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,358.76. The transfer capital threshold is the transfer adjustment factor * $2,358.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33440.86","33440.86","33440.86","1 through 10","30248.78","34649.0782","other","Inpatient Replacement Plans DRG"
"Cholecystectomy With C.D.E. With McC","411","MS-DRG","","","","","","","","inpatient","","","87271.17","65453.38","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28047.16","","Case rate ($28,619.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $29,400.05, add-ons for qualifying new technology services are included. If operating cost exceeds $74,542.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,129.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $26,432.47. The transfer operating threshold is the transfer adjustment factor * $29,400.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,187.08. The transfer capital threshold is the transfer adjustment factor * $2,187.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","61346.89","61346.89","61346.89","1 through 10","27060.2596","29478.14","other","Inpatient DRG"
"Cholecystectomy With C.D.E. Without Cc/McC","413","MS-DRG","","","","","","","","inpatient","","","65074.97","48806.23","MEDICARE [2001]","HB NWH MEDICARE","15818.27","","Case rate ($15,818.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,778.79, add-ons for qualifying new technology services are included. If operating cost exceeds $59,921.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,041.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,718.86. The transfer operating threshold is the transfer adjustment factor * $14,778.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.40. The transfer capital threshold is the transfer adjustment factor * $1,099.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15895.70","15895.70","15895.70","1 through 10","14098.73","16440.4625","other","Inpatient DRG"
"Cholecystectomy With C.D.E. Without Cc/McC","413","MS-DRG","","","","","","","","inpatient","","","65074.97","48806.23","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14098.73","","Case rate ($14,386.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,778.79, add-ons for qualifying new technology services are included. If operating cost exceeds $59,921.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,041.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,287.05. The transfer operating threshold is the transfer adjustment factor * $14,778.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.40. The transfer capital threshold is the transfer adjustment factor * $1,099.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14177.03","14177.03","14177.03","1 through 10","14098.73","16440.4625","other","Inpatient DRG"
"Cholecystectomy,EXTREME","263","DRG","","","","","","","","inpatient","","","107304.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","76236.75","","Standard inlier is a Case rate ($76,236.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $89,859, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,822.10) for the length of stay and the standard reimbursement.","76236.74","76236.74","76236.74","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","48615.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44375.42","","Standard inlier is a Case rate ($44,375.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,298.90) for the length of stay and the standard reimbursement.","44375.42","44375.42","44375.42","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","48615.38","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","18532.7608","","Fee schedule rate ($36,263.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18532.7608","36263.24","36263.24","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","48615.38","","MASSHEALTH [3001]","HB NWH MEDICAID","15164.91","","Case rate ($16,337.79). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,767.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16379.81","16379.81","16379.81","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","48615.38","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","44432.96","","Fee schedule rate ($44,432.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44432.96","44432.96","44432.96","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25689.27","","Standard inlier is a Case rate ($25,689.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,646.69) for the length of stay and the standard reimbursement.","25689.26","25689.26","76680.90","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27595.40","","Standard inlier is a Case rate ($27,595.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,917.05) for the length of stay and the standard reimbursement.","27595.39","26341.06","34979.45","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17650.3344","","Fee schedule rate ($17,650.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17650.3344","17650.34","17650.34","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","MASSHEALTH [3001]","HB NWH MEDICAID","8498.06","","Case rate ($9,155.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,585.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2341.55","2341.55","2341.55","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","10349.17","","Fee schedule rate ($10,349.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10349.09","10349.09","10349.09","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","48447.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25951.29","","Fee schedule rate ($25,951.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25951.29","25951.29","25951.29","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32563.27","","Standard inlier is a Case rate ($32,563.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $45,053, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,622.48) for the length of stay and the standard reimbursement.","32563.27","31083.54","82325.01","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34979.45","","Standard inlier is a Case rate ($34,979.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $45,053, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,965.19) for the length of stay and the standard reimbursement.","34979.45","33389.47","34979.45","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17650.3344","","Fee schedule rate ($23,852.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17650.3344","23852.96","23852.96","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","MASSHEALTH [3001]","HB NWH MEDICAID","10886.75","","Case rate ($11,728.75). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,158.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11758.92","11758.92","11758.92","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33109.80","","Fee schedule rate ($33,109.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33109.80","33109.80","33109.80","1 through 10","8498.06","129540.27","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","56392.93","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","10886.75","","Case rate ($11,728.75). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,158.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12208.75","12208.75","12208.75","1 through 10","8498.06","129540.27","case rate",""
"Cholecystost Perc Compl Px","PX-75000245","CDM","47490","CPT","0361","RC","","","","both","","","5727.00","4295.25","MEDICARE [2001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","2545.65","4461.91","other","OPPS APC"
"Cholecystost Perc Compl Px","PX-75000245","CDM","47490","CPT","0361","RC","","","","outpatient","","","5727.00","4295.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","6233.59","6233.59","6233.59","1 through 10","2652.59","7939.38","other","Multiple Surgery"
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB CH AETNA HMO / PPO","39.64","58.3","","37.42","37.42","37.42","1 through 10","8.03","64.6","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","outpatient","","","68.00","51.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","40.32","59.3","","37.77","37.77","37.77","1 through 10","8.45","53.35","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","72.00","54.00","AETNA [1001]","HB CH AETNA HMO / PPO","41.98","58.3","","39.69","39.69","79.38","16","10.29","68.4","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","72.00","54.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","52.56","73","","39.69","39.69","39.69","1 through 10","10.29","68.4","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","72.00","54.00","TRICARE [160005]","HB NWH TRICARE","68.40","95","","12.65","12.65","12.65","1 through 10","10.29","68.4","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","72.00","54.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.70","59.3","","41.02","41.02","41.02","1 through 10","9.47","57.78","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.48","78.45","","53.82","29.40","53.82","13","9.47","57.78","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","36.00","27.00","AETNA [1001]","HB CH AETNA HMO / PPO","20.99","58.3","","19.85","19.85","19.85","13","4.26","34.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","36.00","27.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.35","59.3","","20.51","20.34","20.51","1 through 10","4.48","28.24","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","36.00","27.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.24","78.45","","26.91","26.91","26.91","1 through 10","4.48","28.24","percent of total billed charges",""
"Cholinesterase Serum","PX-30000365","CDM","82480","CPT","0301","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB CH AETNA HMO / PPO","54.80","58.3","","51.60","51.60","51.60","1 through 10","7.71","89.3","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","both","","","166.00","124.50","AETNA [1001]","HB CH AETNA HMO / PPO","96.78","58.3","","91.29","91.29","91.29","1 through 10","19.87","157.7","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","outpatient","","","166.00","124.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","98.44","59.3","","94.35","94.35","94.35","1 through 10","20.91","130.23","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","outpatient","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","130.23","78.45","","123.78","123.77","123.78","1 through 10","20.91","130.23","percent of total billed charges",""
"Chromium on Fluid","PX-30003420","CDM","84999","CPT","0301","RC","","","","outpatient","","","683.00","512.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","535.81","78.45","","38.44","38.44","38.44","1 through 10","4.28","535.81","percent of total billed charges",""
"Chronic Kidney Disease,MAJOR","470","DRG","","","","","","","","inpatient","","","24209.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20886.78","","Standard inlier is a Case rate ($20,886.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,074, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,964.96) for the length of stay and the standard reimbursement.","20886.78","20886.78","20886.78","1 through 10","9097.88","22813.58","case rate",""
"Chronic Kidney Disease,MAJOR","470","DRG","","","","","","","","inpatient","","","24209.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22436.57","","Standard inlier is a Case rate ($22,436.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,074, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,184.78) for the length of stay and the standard reimbursement.","22436.56","22436.56","22436.56","1 through 10","9097.88","22813.58","case rate",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","18272.16","13704.12","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7522.79","","Case rate ($7,303.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,502.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,645.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,500.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,745.55. The transfer operating threshold is the transfer adjustment factor * $7,502.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.14. The transfer capital threshold is the transfer adjustment factor * $558.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7712.64","7712.64","7728.56","1 through 10","7157.61","8653.4","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","18272.16","13704.12","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8030.58","","Case rate ($8,030.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,502.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,645.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,500.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,472.45. The transfer operating threshold is the transfer adjustment factor * $7,502.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.14. The transfer capital threshold is the transfer adjustment factor * $558.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8082.71","8082.71","8082.71","1 through 10","7157.61","8653.4","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","18272.16","13704.12","MEDICARE [2001]","HB NWH MEDICARE","8030.58","","Case rate ($8,030.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,502.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,645.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,500.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,472.45. The transfer operating threshold is the transfer adjustment factor * $7,502.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.14. The transfer capital threshold is the transfer adjustment factor * $558.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8199.29","2412.97","8214.14","19","7157.61","8653.4","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","18272.16","13704.12","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7157.61","","Case rate ($7,303.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,502.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,645.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,500.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,745.55. The transfer operating threshold is the transfer adjustment factor * $7,502.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.14. The transfer capital threshold is the transfer adjustment factor * $558.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7328.81","7328.81","7341.12","1 through 10","7157.61","8653.4","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","18272.16","13704.12","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7157.61","","Case rate ($7,303.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,502.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,645.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,500.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,745.55. The transfer operating threshold is the transfer adjustment factor * $7,502.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.14. The transfer capital threshold is the transfer adjustment factor * $558.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7322.92","7322.92","7322.92","1 through 10","7157.61","8653.4","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9884.93","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10083.73","10083.73","10083.73","1 through 10","9405.08","11105.347","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9597.02","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9687.06","9687.06","9687.06","1 through 10","9405.08","11105.347","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","ELDER SERVICES [1037]","HB NWH MEDICARE","9597.02","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9575.27","9575.27","9575.27","1 through 10","9405.08","11105.347","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","MEDICARE [2001]","HB NWH MEDICARE","9597.02","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10718.10","1377.30","10737.37","52","9405.08","11105.347","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9405.08","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9584.37","9576.37","9607.36","1 through 10","9405.08","11105.347","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24157.96","18118.47","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9405.08","","Case rate ($9,597.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,858.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,001.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,675.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,863.64. The transfer operating threshold is the transfer adjustment factor * $9,858.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $733.40. The transfer capital threshold is the transfer adjustment factor * $733.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9611.87","9594.73","11156.76","1 through 10","9405.08","11105.347","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","16228.35","12171.26","MEDICARE [2001]","HB NWH MEDICARE","6115.82","","Case rate ($6,115.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,713.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,856.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,367.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,690.76. The transfer operating threshold is the transfer adjustment factor * $5,713.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.06. The transfer capital threshold is the transfer adjustment factor * $425.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6188.09","6188.09","6188.09","1 through 10","5451","6400.1608","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","32694.52","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30436.84","","Standard inlier is a Case rate ($30,436.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,320.38) for the length of stay and the standard reimbursement.","30436.83","30436.83","30436.83","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","32694.52","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11518.0548","","Fee schedule rate ($41,198.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11518.0548","41198.44","41198.44","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","32694.52","","MASSHEALTH [3001]","HB NWH MEDICAID","11198.61","","Case rate ($12,064.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,494.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12095.76","12095.76","12558.49","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","32694.52","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","30062.41","","Fee schedule rate ($30,062.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30062.41","30062.41","30062.41","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","23103.08","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20580.02","","Standard inlier is a Case rate ($20,580.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,301, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,921.25) for the length of stay and the standard reimbursement.","20580.02","19644.56","20580.02","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","23103.08","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11518.0548","","Fee schedule rate ($21,335.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11518.0548","21335.96","21335.96","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","23103.08","","MASSHEALTH [3001]","HB NWH MEDICAID","6950.15","","Case rate ($7,487.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,917.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7506.95","271.09","7506.95","1 through 10","4553.47","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MINOR","140","DRG","","","","","","","","inpatient","","","10976.29","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11518.0548","","Fee schedule rate ($14,795.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11518.0548","11518.06","11518.06","1 through 10","4553.47","67976.8","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","75831.90","56873.92","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","21079.59","","Case rate ($21,079.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,694.38, add-ons for qualifying new technology services are included. If operating cost exceeds $64,836.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,407.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $19,614.51. The transfer operating threshold is the transfer adjustment factor * $19,694.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,465.07. The transfer capital threshold is the transfer adjustment factor * $1,465.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12276.01","12276.01","12276.01","1 through 10","18788.11","21887.3237","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","75831.90","56873.92","MEDICARE [2001]","HB NWH MEDICARE","21079.59","","Case rate ($21,079.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,694.38, add-ons for qualifying new technology services are included. If operating cost exceeds $64,836.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,407.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $19,614.51. The transfer operating threshold is the transfer adjustment factor * $19,694.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,465.07. The transfer capital threshold is the transfer adjustment factor * $1,465.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21162.09","21162.09","21162.09","1 through 10","18788.11","21887.3237","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","58123.06","43592.29","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9271.27","","Case rate ($9,271.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,524.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,666.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,650.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,562.77. The transfer operating threshold is the transfer adjustment factor * $9,524.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.50. The transfer capital threshold is the transfer adjustment factor * $708.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10233.89","10233.89","10233.89","1 through 10","9085.84","10984.58","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","58123.06","43592.29","MEDICARE [2001]","HB NWH MEDICARE","9271.27","","Case rate ($9,271.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,524.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,666.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,650.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,562.77. The transfer operating threshold is the transfer adjustment factor * $9,524.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.50. The transfer capital threshold is the transfer adjustment factor * $708.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10418.98","10400.29","10418.98","1 through 10","9085.84","10984.58","other","Inpatient Replacement Plans DRG"
"Circumcision W/Clamp or Othr Device","PX-76001306","CDM","54150","CPT","0723","RC","","","","outpatient","","","398.00","298.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2876.82","2817.13","2876.82","1 through 10","170.74","1989.5","other","ASC "
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","AETNA [1001]","HB CH AETNA HMO / PPO","3402.39","58.3","","7293.89","5990.92","7293.89","1 through 10","1565.78","4546.83","percent of total billed charges",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","4055.37","3898.79","4055.37","1 through 10","1565.78","4546.83","other","Multiple Surgery"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","MEDICARE [2001]","HB NWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","1565.78","4546.83","other","OPPS APC"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","1565.78","4546.83","per diem",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","WELLPOINT [1015]","HB CH WELLPOINT","4546.83","77.91","","8321.78","8321.78","8321.78","1 through 10","1565.78","4546.83","percent of total billed charges",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2813.15","2872.84","1 through 10","1565.78","4578.34","other","ASC "
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","1408.57","2876.82","13","1565.78","4578.34","other","ASC "
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","11038.74","3679.58","11038.74","1 through 10","1565.78","4578.34","other","Multiple Surgery"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","32618.60","24463.95","MEDICARE [2001]","HB NWH MEDICARE","10061.58","","Case rate ($10,061.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,400.40, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,641.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,362.28. The transfer operating threshold is the transfer adjustment factor * $9,400.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.30. The transfer capital threshold is the transfer adjustment factor * $699.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10210.36","10210.36","10228.70","1 through 10","8967.82","10579.2522","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","32618.60","24463.95","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8967.82","","Case rate ($9,150.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,400.40, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,641.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,451.54. The transfer operating threshold is the transfer adjustment factor * $9,400.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.30. The transfer capital threshold is the transfer adjustment factor * $699.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9151.53","9151.53","9156.89","1 through 10","8967.82","10579.2522","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","40668.93","30501.70","MEDICARE [2001]","HB NWH MEDICARE","17052.35","","Case rate ($17,052.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,517.38, add-ons for qualifying new technology services are included. If operating cost exceeds $62,659.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,245.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,749.22. The transfer operating threshold is the transfer adjustment factor * $17,517.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,303.12. The transfer capital threshold is the transfer adjustment factor * $1,303.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18731.60","18697.74","18731.60","1 through 10","16711.3","20203.57","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","40668.93","30501.70","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16711.30","","Case rate ($17,052.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,517.38, add-ons for qualifying new technology services are included. If operating cost exceeds $62,659.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,245.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,749.22. The transfer operating threshold is the transfer adjustment factor * $17,517.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,303.12. The transfer capital threshold is the transfer adjustment factor * $1,303.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16736.72","16736.72","16736.72","1 through 10","16711.3","20203.57","other","Inpatient DRG"
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","AETNA [1001]","HB CH AETNA HMO / PPO","1880.18","58.3","","464.71","67.87","1012.10","221","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1880.18","58.3","","293.04","293.04","293.04","11","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1709.25","53","","983.89","983.89","983.89","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1870.50","58","","677.18","677.18","677.18","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2015.63","62.5","","46.58","46.58","46.58","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2354.25","73","","747.15","747.15","747.15","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1433.51","44.45","","1141.67","481.21","1141.67","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1433.51","44.45","","76.54","76.54","76.54","1 through 10","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3225.00","2418.75","WELLPOINT [1015]","HB CH WELLPOINT","2512.60","77.91","","273.64","94.28","1367.51","138","1433.51","2512.6","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1912.43","59.3","","720.78","230.14","2010.94","427","1612.5","2530.01","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1912.43","59.3","","344.45","344.45","344.45","1 through 10","1612.5","2530.01","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2530.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1612.5","2530.01","percent of total billed charges",""
"CLAMP ROD VERSATIE 5/6MM","SUP-ITM-10249790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3225.00","2418.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2530.01","78.45","","456.17","105.33","1284.66","242","1612.5","2530.01","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","AETNA [1001]","HB CH AETNA HMO / PPO","2086.56","58.3","","464.71","67.87","1012.10","221","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2086.56","58.3","","293.04","293.04","293.04","11","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.87","53","","983.89","983.89","983.89","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2075.82","58","","677.18","677.18","677.18","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2236.88","62.5","","46.58","46.58","46.58","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2612.67","73","","747.15","747.15","747.15","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.87","44.45","","1141.67","481.21","1141.67","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.87","44.45","","76.54","76.54","76.54","1 through 10","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","WELLPOINT [1015]","HB CH WELLPOINT","2788.40","77.91","","273.64","94.28","1367.51","138","1590.87","2788.4","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2122.35","59.3","","720.78","230.14","2010.94","427","1789.5","2807.73","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2122.35","59.3","","344.45","344.45","344.45","1 through 10","1789.5","2807.73","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2807.73","78.45","","1120.13","1120.13","1120.13","1 through 10","1789.5","2807.73","percent of total billed charges",""
"CLAVICLE PLATE 11X88MM LARGE 8 HOLE BONE TITANIUM LOCKING MIDSHAFT SUPERIOR LOW PROFILE LEFT 70-0287","SUP-ITM-10073389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2807.73","78.45","","456.17","105.33","1284.66","242","1789.5","2807.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","AETNA [1001]","HB CH AETNA HMO / PPO","2100.55","58.3","","464.71","67.87","1012.10","221","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2100.55","58.3","","293.04","293.04","293.04","11","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1909.59","53","","983.89","983.89","983.89","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2089.74","58","","677.18","677.18","677.18","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2251.88","62.5","","46.58","46.58","46.58","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2630.19","73","","747.15","747.15","747.15","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1601.53","44.45","","1141.67","481.21","1141.67","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1601.53","44.45","","76.54","76.54","76.54","1 through 10","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","WELLPOINT [1015]","HB CH WELLPOINT","2807.10","77.91","","273.64","94.28","1367.51","138","1601.53","2807.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2136.58","59.3","","720.78","230.14","2010.94","427","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2136.58","59.3","","344.45","344.45","344.45","1 through 10","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2826.55","78.45","","1120.13","1120.13","1120.13","1 through 10","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2826.55","78.45","","456.17","105.33","1284.66","242","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","AETNA [1001]","HB CH AETNA HMO / PPO","2343.10","58.3","","464.71","67.87","1012.10","221","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2343.10","58.3","","293.04","293.04","293.04","11","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2130.09","53","","983.89","983.89","983.89","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2331.04","58","","677.18","677.18","677.18","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2511.90","62.5","","46.58","46.58","46.58","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2933.90","73","","747.15","747.15","747.15","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.46","44.45","","1141.67","481.21","1141.67","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.46","44.45","","76.54","76.54","76.54","1 through 10","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","both","","","4019.04","3014.28","WELLPOINT [1015]","HB CH WELLPOINT","3131.23","77.91","","273.64","94.28","1367.51","138","1786.46","3131.23","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4019.04","3014.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","2383.29","59.3","","720.78","230.14","2010.94","427","2009.52","3152.94","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4019.04","3014.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2383.29","59.3","","344.45","344.45","344.45","1 through 10","2009.52","3152.94","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4019.04","3014.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3152.94","78.45","","1120.13","1120.13","1120.13","1 through 10","2009.52","3152.94","percent of total billed charges",""
"CLAVICLE PLATE 99MM 6 HOLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LEFT","SUP-ITM-10144650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4019.04","3014.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3152.94","78.45","","456.17","105.33","1284.66","242","2009.52","3152.94","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","464.71","67.87","1012.10","221","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","293.04","293.04","293.04","11","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","983.89","983.89","983.89","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","677.18","677.18","677.18","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","46.58","46.58","46.58","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","747.15","747.15","747.15","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1141.67","481.21","1141.67","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","76.54","76.54","76.54","1 through 10","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","273.64","94.28","1367.51","138","733.43","1285.52","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","720.78","230.14","2010.94","427","825","1294.43","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","344.45","344.45","344.45","1 through 10","825","1294.43","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1120.13","1120.13","1120.13","1 through 10","825","1294.43","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","456.17","105.33","1284.66","242","825","1294.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","464.71","67.87","1012.10","221","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","293.04","293.04","293.04","11","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","983.89","983.89","983.89","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2246.48","58","","677.18","677.18","677.18","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.78","62.5","","46.58","46.58","46.58","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","747.15","747.15","747.15","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","1141.67","481.21","1141.67","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","76.54","76.54","76.54","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","273.64","94.28","1367.51","138","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","720.78","230.14","2010.94","427","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.83","59.3","","344.45","344.45","344.45","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","456.17","105.33","1284.66","242","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","464.71","67.87","1012.10","221","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","293.04","293.04","293.04","11","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","983.89","983.89","983.89","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2246.48","58","","677.18","677.18","677.18","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.78","62.5","","46.58","46.58","46.58","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","747.15","747.15","747.15","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","1141.67","481.21","1141.67","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","76.54","76.54","76.54","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","273.64","94.28","1367.51","138","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","720.78","230.14","2010.94","427","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.83","59.3","","344.45","344.45","344.45","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10X15 13MM EASY NITINOL ALLOY LOW PROFILE MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","456.17","105.33","1284.66","242","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","464.71","67.87","1012.10","221","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","293.04","293.04","293.04","11","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","983.89","983.89","983.89","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2246.48","58","","677.18","677.18","677.18","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.78","62.5","","46.58","46.58","46.58","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","747.15","747.15","747.15","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","1141.67","481.21","1141.67","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","76.54","76.54","76.54","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","273.64","94.28","1367.51","138","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","720.78","230.14","2010.94","427","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.83","59.3","","344.45","344.45","344.45","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","456.17","105.33","1284.66","242","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","464.71","67.87","1012.10","221","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","293.04","293.04","293.04","11","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","983.89","983.89","983.89","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2246.48","58","","677.18","677.18","677.18","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.78","62.5","","46.58","46.58","46.58","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","747.15","747.15","747.15","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","1141.67","481.21","1141.67","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","76.54","76.54","76.54","1 through 10","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","273.64","94.28","1367.51","138","1721.66","3017.64","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","720.78","230.14","2010.94","427","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.83","59.3","","344.45","344.45","344.45","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","456.17","105.33","1284.66","242","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","AETNA [1001]","HB CH AETNA HMO / PPO","2547.62","58.3","","464.71","67.87","1012.10","221","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2547.62","58.3","","293.04","293.04","293.04","11","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2316.02","53","","983.89","983.89","983.89","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2534.51","58","","677.18","677.18","677.18","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2731.16","62.5","","46.58","46.58","46.58","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3189.99","73","","747.15","747.15","747.15","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.40","44.45","","1141.67","481.21","1141.67","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.40","44.45","","76.54","76.54","76.54","1 through 10","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","WELLPOINT [1015]","HB CH WELLPOINT","3404.55","77.91","","273.64","94.28","1367.51","138","1942.4","3404.55","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2591.32","59.3","","720.78","230.14","2010.94","427","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2591.32","59.3","","344.45","344.45","344.45","1 through 10","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3428.15","78.45","","1120.13","1120.13","1120.13","1 through 10","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 18X12MM EASY MONOCORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10041872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3428.15","78.45","","456.17","105.33","1284.66","242","2184.93","3428.15","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/O Stabilization","PX-76000325","CDM","21315","CPT","0761","RC","","","","both","","","1832.00","1374.00","AETNA [1001]","HB CH AETNA HMO / PPO","1068.06","58.3","","3384.99","3384.99","3384.99","1 through 10","62.43","1723.75","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/O Stabilization","PX-76000325","CDM","21315","CPT","0761","RC","","","","outpatient","","","1832.00","1374.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1462.72","","Case rate ($1,462.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2115.09","2115.09","2115.09","1 through 10","916","1873.9","other","ASC "
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","outpatient","","","4094.00","3070.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4719.13","4719.13","4719.13","1 through 10","2008.14","4472.66","other","Multiple Surgery"
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","outpatient","","","1284.00","963.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","798.50","798.50","798.50","1 through 10","482.89","1007.3","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","4610.00","3457.50","MEDICARE [2001]","HB NWH MEDICARE","2326.32","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1548.96","3591.65","other","OPPS APC"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2557.79","2557.79","2557.79","1 through 10","1548.96","4472.66","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1280.67","1280.67","2508.19","1 through 10","1548.96","4472.66","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3640.06","3640.06","3640.06","1 through 10","1548.96","4472.66","other","Multiple Surgery"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3616.55","78.45","","4589.74","4589.74","4589.74","1 through 10","1548.96","4472.66","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","outpatient","","","2450.00","1837.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1452.85","59.3","","1395.85","1395.85","1395.85","1 through 10","1089.03","3920.8","percent of total billed charges",""
"Cmapc, Mayo Chromosomal Microarry Autopsy Products of Conception Stillborn Varies","PX-31001272","CDM","81229","CPT","0310","RC","","","","outpatient","","","2450.00","1837.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1452.85","59.3","","1395.85","1395.85","1395.85","1 through 10","1089.03","3920.8","percent of total billed charges",""
"Coag Fibrinolysis Func Activity Nos","PX-30001094","CDM","85397","CPT","0305","RC","","","","outpatient","","","269.00","201.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.03","78.45","","201.43","201.43","201.43","1 through 10","23.65","211.03","percent of total billed charges",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","46463.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","58680.05","","Standard inlier is a Case rate ($58,680.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $67,689, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,329.39) for the length of stay and the standard reimbursement.","58680.05","58680.05","58680.05","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","46463.40","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16038.1194","","Fee schedule rate ($89,877.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16038.1194","89877.56","89877.56","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","21330.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30805.51","","Standard inlier is a Case rate ($30,805.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $41,069, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,372.71) for the length of stay and the standard reimbursement.","3969.89","3969.89","3969.89","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","21330.05","","MASSHEALTH [3001]","HB NWH MEDICAID","16373.53","","Case rate ($17,639.90). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $60,069.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7233.23","7233.23","7233.23","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","17532.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16667.75","","Standard inlier is a Case rate ($16,667.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,747, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,366.05) for the length of stay and the standard reimbursement.","15911.33","15911.33","16667.74","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","17532.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17904.49","","Standard inlier is a Case rate ($17,904.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,747, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,541.47) for the length of stay and the standard reimbursement.","17904.48","17904.48","17904.48","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","17532.29","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19652.46","","Fee schedule rate ($19,652.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19652.46","19652.46","19652.46","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","48723.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23845.44","","Standard inlier is a Case rate ($23,845.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,422, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,384.76) for the length of stay and the standard reimbursement.","22761.55","22761.55","22761.55","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","48723.79","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","23269.42","","Fee schedule rate ($23,269.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22372.04","22372.04","22372.04","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","48723.79","","MASSHEALTH [3001]","HB NWH MEDICAID","11084.38","","Case rate ($11,941.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,371.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11972.38","11972.38","11972.38","1 through 10","7837.25","148296.6","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","48723.79","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28543.74","","Fee schedule rate ($28,543.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28543.74","28543.74","28543.74","1 through 10","7837.25","148296.6","case rate",""
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13611.53","","Case rate ($13,215.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,205.20. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13874.59","13874.59","13874.59","1 through 10","12950.78","15657.2","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14530.31","","Case rate ($14,530.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $13,520.43. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13353.14","13353.14","14564.12","1 through 10","12950.78","15657.2","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","HUMANA [1012]","HB NWH MEDICARE","14530.31","","Case rate ($14,530.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $13,520.43. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12344.71","12344.71","12344.71","1 through 10","12950.78","15657.2","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","MEDICARE [2001]","HB NWH MEDICARE","14530.31","","Case rate ($14,530.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $13,520.43. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14774.37","14774.18","14800.93","77","12950.78","15657.2","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12950.78","","Case rate ($13,215.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,205.20. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13211.54","13199.04","15577.46","1 through 10","12950.78","15657.2","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","29330.27","21997.70","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12950.78","","Case rate ($13,215.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,575.48, add-ons for qualifying new technology services are included. If operating cost exceeds $58,717.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,205.20. The transfer operating threshold is the transfer adjustment factor * $13,575.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.88. The transfer capital threshold is the transfer adjustment factor * $1,009.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13234.35","13234.35","13238.54","1 through 10","12950.78","15657.2","other","Inpatient DRG"
"Cobalt, Fluid","PX-30003421","CDM","84999","CPT","0301","RC","","","","outpatient","","","640.00","480.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","502.08","78.45","","38.44","38.44","38.44","1 through 10","4.28","502.08","percent of total billed charges",""
"Cocaine Abuse And Dependence,MAJOR","774","DRG","","","","","","","","inpatient","","","27827.03","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","8260.45","","Case rate ($8,899.33). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,329.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","954.59","39764.34","case rate",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","29","60.9","404.7","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","TRICARE [160005]","HB NWH TRICARE","404.70","95","","74.88","71.14","74.88","1 through 10","60.9","404.7","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.36","44.45","","188.62","188.62","188.62","1 through 10","60.9","404.7","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","236.81","1141.80","37","176.68","603.55","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","28","176.68","603.55","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","115.00","86.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.20","59.3","","65.63","65.63","65.63","1 through 10","11.84","90.22","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.22","78.45","","86.11","86.11","86.11","1 through 10","11.84","90.22","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","AETNA [1001]","HB CH AETNA HMO / PPO","544.17","58.3","","2190.90","412.50","9264.59","16","414.9","727.21","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","541.37","58","","1903.20","1903.20","3826.66","1 through 10","414.9","727.21","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","583.38","62.5","","2186.25","2186.25","2186.25","32","414.9","727.21","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","681.38","73","","5556.60","5556.60","5556.60","1 through 10","414.9","727.21","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","WELLPOINT [1015]","HB CH WELLPOINT","727.21","77.91","","1955.15","885.83","3150.40","26","414.9","727.21","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","933.40","700.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","553.51","59.3","","831.03","253.22","2394.88","18","466.7","732.25","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","933.40","700.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","732.25","78.45","","2481.69","1563.74","8149.28","1 through 10","466.7","732.25","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","AETNA [1001]","HB CH AETNA HMO / PPO","2255.50","58.3","","2190.90","412.50","9264.59","16","1719.68","3014.17","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2243.90","58","","1903.20","1903.20","3826.66","1 through 10","1719.68","3014.17","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2417.99","62.5","","2186.25","2186.25","2186.25","32","1719.68","3014.17","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2824.22","73","","5556.60","5556.60","5556.60","1 through 10","1719.68","3014.17","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","WELLPOINT [1015]","HB CH WELLPOINT","3014.17","77.91","","1955.15","885.83","3150.40","26","1719.68","3014.17","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3868.79","2901.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.19","59.3","","831.03","253.22","2394.88","18","1934.4","3035.07","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3868.79","2901.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3035.07","78.45","","2481.69","1563.74","8149.28","1 through 10","1934.4","3035.07","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","AETNA [1001]","HB CH AETNA HMO / PPO","2595.32","58.3","","2190.90","412.50","9264.59","16","1978.77","3468.3","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2581.97","58","","1903.20","1903.20","3826.66","1 through 10","1978.77","3468.3","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2782.29","62.5","","2186.25","2186.25","2186.25","32","1978.77","3468.3","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3249.72","73","","5556.60","5556.60","5556.60","1 through 10","1978.77","3468.3","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","WELLPOINT [1015]","HB CH WELLPOINT","3468.30","77.91","","1955.15","885.83","3150.40","26","1978.77","3468.3","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4451.67","3338.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2639.84","59.3","","831.03","253.22","2394.88","18","2225.84","3492.34","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4451.67","3338.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3492.34","78.45","","2481.69","1563.74","8149.28","1 through 10","2225.84","3492.34","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","243.82","1 through 10","23.61","209.95","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","165.29","165.29","165.29","1 through 10","23.61","209.95","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","92.83","92.83","92.83","1 through 10","18.62","173.37","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","18.62","173.37","percent of total billed charges",""
"Cold Agglutinin Titer","PX-30000797","CDM","86157","CPT","0302","RC","","","","outpatient","","","74.00","55.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.05","78.45","","32.80","32.80","32.80","1 through 10","8.32","58.05","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","1 through 10","18.31","143.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","1 through 10","13.15","118.46","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.12","44.45","","113.01","113.01","113.01","1 through 10","13.15","118.46","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","113.01","113.01","1 through 10","13.15","118.46","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","269.00","201.75","MEDICARE [2001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.11","153.08","380.11","1 through 10","142.57","414.21","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","269.00","201.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","136.63","136.63","136.63","1 through 10","142.57","414.21","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","269.00","201.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","176.08","176.08","176.08","1 through 10","119.57","263.01","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB CH AETNA HMO / PPO","1444.09","58.3","","1365.90","1365.90","1365.90","39","744.89","1808.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1026.44","1114.11","11","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","981.55","1065.39","25","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","234","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","29","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","977.56","1061.06","33","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1204.47","1230.03","108","744.89","1943.21","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1231.73","1231.73","1 through 10","744.89","1943.21","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","615.87","1231.73","258","744.89","1943.21","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1468.86","59.3","","1411.67","1411.67","2755.90","38","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1101.03","44.45","","1852.04","1097.54","1852.04","1 through 10","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1943.21","78.45","","1852.04","1852.04","1852.04","21","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB CH AETNA HMO / PPO","1444.09","58.3","","1365.90","1365.90","1365.90","76","744.89","1808.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","557.06","1114.11","11","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","32","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","HUMANA [1012]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","977.56","977.56","977.56","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","182","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","24","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.54","1061.06","19","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1204.47","1230.03","148","744.89","1943.21","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","1206.18","1206.18","1 through 10","744.89","1943.21","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1206.18","1231.73","347","744.89","1943.21","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1468.86","59.3","","1411.67","1411.67","1411.67","64","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1943.21","78.45","","1852.04","1852.04","1852.04","1 through 10","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1101.03","44.45","","1097.54","1097.54","1097.54","1 through 10","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1943.21","78.45","","1852.04","1097.54","1852.04","40","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1512.00","1134.00","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","744.89","2783.98","other","OPPS APC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1512.00","1134.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1206.18","1231.73","1 through 10","672.08","1873.9","other","ASC "
"Colon Cancer Scr Sigmoidoscopy|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","74","both","","","1512.00","1134.00","MEDICARE [2001]","HB NWH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","648.65","2028.34","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB CH AETNA HMO / PPO","1479.65","58.3","","1399.36","1399.36","2798.72","27","979.79","1919.74","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","720.42","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2172.52","1217.71","2537.66","32","979.79","1919.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","700.11","1400.23","90","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MOLINA [1014]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1386.24","1386.24","1386.24","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1852.74","73","","2097.80","1399.36","2097.80","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","72","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1584.32","1584.32","1617.93","23","979.79","1991.06","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","810.09","810.09","810.09","1 through 10","979.79","1991.06","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","76","979.79","1991.06","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1505.03","59.3","","1446.25","1445.68","1446.25","43","979.79","1991.06","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2214.33","11512.55","36","979.79","1991.06","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2493.76","1268.83","7260.24","24","979.79","1991.06","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1991.06","78.45","","1897.39","1124.42","1897.40","1 through 10","979.79","1991.06","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB CH AETNA HMO / PPO","2115.71","58.3","","2000.94","2000.94","2000.94","16","744.89","2649.17","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","557.06","1114.11","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","532.70","1065.39","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2189.98","2189.98","2189.98","12","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1825.89","1429.36","1929.27","58","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","43","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","19","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","62","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1702.00","1788.00","12","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","157","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TRICARE [160005]","HB NWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1082.71","1082.71","1082.71","1 through 10","744.89","2649.17","other","Tricare OPPS"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1082.71","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1854.78","964.64","1854.78","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","615.02","1230.03","42","744.89","2846.95","other","ASC "
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","615.87","1231.73","89","744.89","2846.95","other","ASC "
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2152.00","59.3","","2067.99","2067.99","2067.99","18","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","875.25","1750.49","255","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1772.84","2189.98","115","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1772.84","1772.84","1772.84","1 through 10","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2846.95","78.45","","2713.10","1607.81","2713.10","12","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flexible With Band Ligation(S)","PX-75000426","CDM","45398","CPT","0750","RC","","","","outpatient","","","3540.00","2655.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1617.93","1617.93","1 through 10","979.79","2777.13","other","ASC "
"Colonoscopy Flexible With Band Ligation(S)","PX-75000426","CDM","45398","CPT","0750","RC","","","","outpatient","","","3540.00","2655.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1586.56","1586.56","1586.56","1 through 10","979.79","2777.13","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB CH AETNA HMO / PPO","2115.71","58.3","","2000.94","2000.94","2000.94","16","744.89","2649.17","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","557.06","1114.11","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","532.70","1065.39","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2189.98","2189.98","2189.98","12","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1825.89","1429.36","1929.27","58","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","43","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","19","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","62","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1702.00","1788.00","12","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","157","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TRICARE [160005]","HB NWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1082.71","1082.71","1082.71","1 through 10","744.89","2649.17","other","Tricare OPPS"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1082.71","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1854.78","964.64","1854.78","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","615.02","1230.03","42","744.89","2846.95","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","615.87","1231.73","89","744.89","2846.95","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2152.00","59.3","","2067.99","2067.99","2067.99","18","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","875.25","1750.49","255","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1772.84","2189.98","115","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1772.84","1772.84","1772.84","1 through 10","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2846.95","78.45","","2713.10","1607.81","2713.10","12","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","2497.00","1872.75","MEDICARE [2001]","HB NWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","979.79","3354.12","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","2497.00","1872.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3191.62","3191.62","3191.62","1 through 10","979.79","3354.12","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","2497.00","1872.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","1 through 10","979.79","1958.9","other","ASC "
"Colonoscopy Stoma W/Biopsy","PX-75000158","CDM","44389","CPT","0750","RC","","","","both","","","2476.00","1857.00","AETNA [1001]","HB CH AETNA HMO / PPO","1443.51","58.3","","1365.34","1365.34","1365.34","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy Stoma W/Snare","PX-75000163","CDM","44394","CPT","0750","RC","","","","both","","","2476.00","1857.00","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","both","","","2476.00","1857.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1082.71","1061.06","1082.71","1 through 10","744.89","1807.48","other","OPPS APC"
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","outpatient","","","2476.00","1857.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","1204.47","1204.47","1 through 10","744.89","1942.42","other","ASC "
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","outpatient","","","2476.00","1857.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1839.88","1839.88","1 through 10","744.89","1942.42","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","AETNA [1001]","HB CH AETNA HMO / PPO","1371.80","58.3","","1297.30","1297.30","1297.30","27","979.79","1919.74","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1440.84","1440.84","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1267.34","1377.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2880.58","2880.58","2880.58","1 through 10","979.79","1919.74","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1990.54","1063.46","2537.66","22","979.79","1919.74","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","HUMANA [1012]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1263.22","1263.22","1263.22","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","81","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","5106.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1788.00","1788.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","5631.00","31","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1717.69","73","","1297.30","1297.30","1297.30","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","11","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1045.91","44.45","","1759.01","1759.01","1759.01","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1262.20","1372.23","49","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1584.32","1617.93","32","979.79","1873.9","other","ASC "
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","117","979.79","1873.9","other","ASC "
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1395.33","59.3","","1340.77","1340.77","4222.72","40","979.79","1873.9","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2302.51","6907.53","69","979.79","1873.9","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","1117.58","7260.24","16","979.79","1873.9","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1395.33","59.3","","979.84","979.84","979.84","1 through 10","979.79","1873.9","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","439.75","439.75","439.75","1 through 10","979.79","1873.9","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1845.93","78.45","","1759.01","1359.97","3355.37","1 through 10","979.79","1873.9","percent of total billed charges",""
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","outpatient","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","500.51","78.45","","476.66","476.66","476.66","1 through 10","165.93","567.68","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","AETNA [1001]","HB CH AETNA HMO / PPO","379.53","58.3","","358.91","358.91","358.91","1 through 10","273","507.19","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","MEDICARE [2001]","HB NWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","361.24","361.24","1 through 10","273","507.19","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","206.55","206.55","206.55","1 through 10","273","507.19","per diem",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","273","507.19","per diem",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($256). Procedure 2, Per diem ($128). Procedures 3 - 9999, Per diem ($64).","243.00","243.00","243.00","1 through 10","273","507.19","per diem",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","273","507.19","per diem",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","361.24","361.24","361.24","1 through 10","273","507.19","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","651.00","488.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","441.44","441.44","441.44","1 through 10","273","970.06","other","ASC "
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","651.00","488.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","451.43","451.43","451.43","1 through 10","273","970.06","other","ASC "
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","651.00","488.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1924.65","641.55","1924.65","1 through 10","273","970.06","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","651.00","488.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","674.31","674.31","674.31","1 through 10","273","970.06","other","Multiple Surgery"
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","1873.9","3628.31","other","Multiple Surgery"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1240.00","930.00","MEDICARE [2001]","HB NWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","531.96","1064.97","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","1873.00","1404.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1440.84","1440.84","1440.84","1 through 10","832.55","1919.74","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","1873.00","1404.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1822.00","1822.00","1822.00","1 through 10","832.55","1919.74","per diem",""
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","1873.00","1404.75","TRICARE [160005]","HB NWH TRICARE","1330.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1400.23","1400.23","1400.23","1 through 10","832.55","1919.74","other","Tricare OPPS"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","outpatient","","","1873.00","1404.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1617.93","1617.93","1 through 10","936.5","1938.84","other","ASC "
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","outpatient","","","1873.00","1404.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1586.56","1586.56","1586.56","1 through 10","936.5","1938.84","other","ASC "
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","outpatient","","","1873.00","1404.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2302.51","2302.51","1 through 10","936.5","1938.84","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB CH AETNA HMO / PPO","1479.65","58.3","","1399.36","1399.36","2798.72","27","979.79","1919.74","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","720.42","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2172.52","1217.71","2537.66","32","979.79","1919.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","700.11","1400.23","90","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MOLINA [1014]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1386.24","1386.24","1386.24","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1852.74","73","","2097.80","1399.36","2097.80","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","72","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1584.32","1584.32","1617.93","23","979.79","1991.06","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","810.09","810.09","810.09","1 through 10","979.79","1991.06","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","76","979.79","1991.06","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1505.03","59.3","","1446.25","1445.68","1446.25","43","979.79","1991.06","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2214.33","11512.55","36","979.79","1991.06","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2493.76","1268.83","7260.24","24","979.79","1991.06","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1991.06","78.45","","1897.39","1124.42","1897.40","1 through 10","979.79","1991.06","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","50","11.76","135.85","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","104.39","73","","202.94","202.94","202.94","1 through 10","11.76","135.85","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB NWH TRICARE","135.85","95","","28.92","28.92","28.92","1 through 10","11.76","135.85","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","44.45","","106.87","106.87","106.87","1 through 10","11.76","135.85","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","244.36","57","12.38","112.18","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","106.87","49","12.38","112.18","percent of total billed charges",""
"Complement Functional Activity","PX-30000799","CDM","86161","CPT","0302","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","112.51","56.26","112.51","1 through 10","12.38","77.67","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1858.00","1393.50","TRICARE [160005]","HB NWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","651.14","651.14","651.14","1 through 10","618.58","1935.24","other","Tricare OPPS"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1858.00","1393.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1101.79","59.3","","1058.90","1058.90","1058.90","1 through 10","821.51","2846.52","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1858.00","1393.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1457.60","78.45","","1389.22","823.27","1389.22","1 through 10","821.51","2846.52","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","122.48","35","17.62","106.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","111.00","83.25","TRICARE [160005]","HB NWH TRICARE","105.45","95","","21.67","21.67","21.67","1 through 10","17.62","106.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","48","18.54","113.33","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","49.20","83.03","30","18.54","113.33","percent of total billed charges",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","28329.44","21247.08","MEDICARE [2001]","HB NWH MEDICARE","10321.65","","Case rate ($10,321.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,643.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,785.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,659.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,604.27. The transfer operating threshold is the transfer adjustment factor * $9,643.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.37. The transfer capital threshold is the transfer adjustment factor * $717.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10413.25","10413.25","10413.25","1 through 10","9199.62","10770.1099","other","Inpatient DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","28329.44","21247.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9199.62","","Case rate ($9,387.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,643.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,785.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,659.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,669.99. The transfer operating threshold is the transfer adjustment factor * $9,643.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.37. The transfer capital threshold is the transfer adjustment factor * $717.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9283.41","9283.41","9283.41","1 through 10","9199.62","10770.1099","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","33471.60","25103.70","MEDICARE [2001]","HB NWH MEDICARE","17000.35","","Case rate ($17,000.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,463.98, add-ons for qualifying new technology services are included. If operating cost exceeds $62,606.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,241.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,701.21. The transfer operating threshold is the transfer adjustment factor * $17,463.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,299.15. The transfer capital threshold is the transfer adjustment factor * $1,299.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18398.86","18398.86","18398.86","1 through 10","16660.34","19029.4027","other","Inpatient Replacement Plans DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","33471.60","25103.70","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16660.34","","Case rate ($17,000.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,463.98, add-ons for qualifying new technology services are included. If operating cost exceeds $62,606.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,241.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,701.21. The transfer operating threshold is the transfer adjustment factor * $17,463.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,299.15. The transfer capital threshold is the transfer adjustment factor * $1,299.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16402.59","16402.59","16402.59","1 through 10","16660.34","19029.4027","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","24210.77","18158.08","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9548.12","","Case rate ($9,548.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,920.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,062.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,884.50. The transfer operating threshold is the transfer adjustment factor * $8,920.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $663.61. The transfer capital threshold is the transfer adjustment factor * $663.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8760.45","8760.45","8760.45","1 through 10","8510.18","10046.2351","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","24210.77","18158.08","MEDICARE [2001]","HB NWH MEDICARE","9548.12","","Case rate ($9,548.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,920.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,062.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,884.50. The transfer operating threshold is the transfer adjustment factor * $8,920.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $663.61. The transfer capital threshold is the transfer adjustment factor * $663.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9695.92","1256.76","9713.34","1 through 10","8510.18","10046.2351","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","24210.77","18158.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8510.18","","Case rate ($8,683.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,920.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,062.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,020.24. The transfer operating threshold is the transfer adjustment factor * $8,920.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $663.61. The transfer capital threshold is the transfer adjustment factor * $663.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8659.33","8659.33","8659.33","1 through 10","8510.18","10046.2351","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","24210.77","18158.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8510.18","","Case rate ($8,683.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,920.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,062.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,605.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,020.24. The transfer operating threshold is the transfer adjustment factor * $8,920.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $663.61. The transfer capital threshold is the transfer adjustment factor * $663.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8836.18","8836.18","8836.18","1 through 10","8510.18","10046.2351","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","32657.45","24493.09","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","16337.78","","Case rate ($15,861.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,294.50, add-ons for qualifying new technology services are included. If operating cost exceeds $61,436.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,649.76. The transfer operating threshold is the transfer adjustment factor * $16,294.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.15. The transfer capital threshold is the transfer adjustment factor * $1,212.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16331.35","16331.35","16331.35","1 through 10","15544.68","18033.5804","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","32657.45","24493.09","MEDICARE [2001]","HB NWH MEDICARE","17440.58","","Case rate ($17,440.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,294.50, add-ons for qualifying new technology services are included. If operating cost exceeds $61,436.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,228.42. The transfer operating threshold is the transfer adjustment factor * $16,294.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.15. The transfer capital threshold is the transfer adjustment factor * $1,212.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17436.06","17404.76","17436.06","1 through 10","15544.68","18033.5804","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","32657.45","24493.09","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15544.68","","Case rate ($15,861.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,294.50, add-ons for qualifying new technology services are included. If operating cost exceeds $61,436.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,649.76. The transfer operating threshold is the transfer adjustment factor * $16,294.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.15. The transfer capital threshold is the transfer adjustment factor * $1,212.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15550.24","15550.24","15582.48","1 through 10","15544.68","18033.5804","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","32657.45","24493.09","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15544.68","","Case rate ($15,861.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,294.50, add-ons for qualifying new technology services are included. If operating cost exceeds $61,436.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,649.76. The transfer operating threshold is the transfer adjustment factor * $16,294.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.15. The transfer capital threshold is the transfer adjustment factor * $1,212.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15559.43","15559.43","15559.43","1 through 10","15544.68","18033.5804","other","Inpatient DRG"
"Complications Of Treatment Without Cc/McC","921","MS-DRG","","","","","","","","inpatient","","","13894.89","10421.17","WELLPOINT [1015]","HB CH WELLPOINT","","77.91","","6800.66","6800.66","6800.66","1 through 10","","","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","AETNA [1001]","HB CH AETNA HMO / PPO","4862.34","58.3","","1530.90","1160.93","1884.08","89","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4420.31","53","","5253.92","5253.92","5253.92","1 through 10","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4837.32","58","","12181.47","12181.47","12181.47","1 through 10","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5212.63","62.5","","1350.68","1350.68","1350.68","1 through 10","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3707.22","44.45","","1910.74","891.94","1910.74","1 through 10","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","8340.20","6255.15","WELLPOINT [1015]","HB CH WELLPOINT","6497.85","77.91","","1829.79","1561.50","2617.12","88","3707.22","6497.85","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8340.20","6255.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","4945.74","59.3","","1359.46","1201.30","1689.00","61","4170.1","6542.89","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8340.20","6255.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4945.74","59.3","","1718.92","1718.92","1718.92","1 through 10","4170.1","6542.89","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8340.20","6255.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6542.89","78.45","","1910.74","1019.06","2344.84","74","4170.1","6542.89","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","AETNA [1001]","HB CH AETNA HMO / PPO","8154.13","58.3","","1530.90","1160.93","1884.08","89","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7412.85","53","","5253.92","5253.92","5253.92","1 through 10","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8112.17","58","","12181.47","12181.47","12181.47","1 through 10","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8741.56","62.5","","1350.68","1350.68","1350.68","1 through 10","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6217.00","44.45","","1910.74","891.94","1910.74","1 through 10","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","13986.50","10489.87","WELLPOINT [1015]","HB CH WELLPOINT","10896.88","77.91","","1829.79","1561.50","2617.12","88","6217","10896.88","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13986.50","10489.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","8293.99","59.3","","1359.46","1201.30","1689.00","61","6993.25","10972.41","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13986.50","10489.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","8293.99","59.3","","1718.92","1718.92","1718.92","1 through 10","6993.25","10972.41","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13986.50","10489.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10972.41","78.45","","1910.74","1019.06","2344.84","74","6993.25","10972.41","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","AETNA [1001]","HB CH AETNA HMO / PPO","3264.80","58.3","","1530.90","1160.93","1884.08","89","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2968.00","53","","5253.92","5253.92","5253.92","1 through 10","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3248.00","58","","12181.47","12181.47","12181.47","1 through 10","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2489.20","44.45","","1910.74","891.94","1910.74","1 through 10","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","both","","","5600.00","4200.00","WELLPOINT [1015]","HB CH WELLPOINT","4362.96","77.91","","1829.79","1561.50","2617.12","88","2489.2","4362.96","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5600.00","4200.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3320.80","59.3","","1359.46","1201.30","1689.00","61","2800","4393.2","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5600.00","4200.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3320.80","59.3","","1718.92","1718.92","1718.92","1 through 10","2800","4393.2","percent of total billed charges",""
"COMPONENT FEMORAL SZ 4 RIGHT ATTUNE CRS CEMENTED","SUP-ITM-10274626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5600.00","4200.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4393.20","78.45","","1910.74","1019.06","2344.84","74","2800","4393.2","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","464.71","67.87","1012.10","221","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","293.04","293.04","293.04","11","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","983.89","983.89","983.89","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","677.18","677.18","677.18","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","46.58","46.58","46.58","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","747.15","747.15","747.15","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1141.67","481.21","1141.67","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","76.54","76.54","76.54","1 through 10","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","273.64","94.28","1367.51","138","1778","3116.4","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","720.78","230.14","2010.94","427","2000","3138","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","344.45","344.45","344.45","1 through 10","2000","3138","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1120.13","1120.13","1120.13","1 through 10","2000","3138","percent of total billed charges",""
"COMPOSITE MODABLE 10CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","456.17","105.33","1284.66","242","2000","3138","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"COMPOSITE MODABLE 2.5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","464.71","67.87","1012.10","221","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","293.04","293.04","293.04","11","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","983.89","983.89","983.89","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","677.18","677.18","677.18","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","46.58","46.58","46.58","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","747.15","747.15","747.15","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1141.67","481.21","1141.67","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","76.54","76.54","76.54","1 through 10","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","273.64","94.28","1367.51","138","1200.15","2103.57","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","720.78","230.14","2010.94","427","1350","2118.15","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","344.45","344.45","344.45","1 through 10","1350","2118.15","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1120.13","1120.13","1120.13","1 through 10","1350","2118.15","percent of total billed charges",""
"COMPOSITE MODABLE 5CC BIOACTIVE MACROFORM NOVABONE PACKABLE","SUP-ITM-10211627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","456.17","105.33","1284.66","242","1350","2118.15","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0300","RC","","","","inpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.20","56","","68.56","68.56","68.56","1 through 10","67.2","84.72","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0300","RC","","","","inpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.72","70.6","","89.95","89.95","89.95","1 through 10","67.2","84.72","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1630","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","85.41","85.41","85.41","1 through 10","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","62.01","66.34","1 through 10","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","62.01","62.01","62.01","1 through 10","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","64.30","20.72","68.56","28","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","TRICARE [160005]","HB NWH TRICARE","114.00","95","","12.72","12.08","12.72","27","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","89.95","53.31","89.95","60","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","53.31","53.31","89.95","1 through 10","10.35","114","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","1620","10.89","94.14","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","66.92","68.56","1 through 10","10.89","94.14","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","86.46","89.96","1 through 10","10.89","94.14","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","53.31","89.95","1448","10.89","94.14","percent of total billed charges",""
"Concussion, Closed Skull Fracture Nos, And Uncomplicated Intracranial Injury, Coma < 1 Hour Or No Coma,MAJOR","057","DRG","","","","","","","","inpatient","","","52563.04","","MASSHEALTH [3001]","HB NWH MEDICAID","10247.02","","Case rate ($11,039.55). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,469.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,016.27 and the sum of the standard inlier and any outlier amount.","11067.94","11067.94","11067.94","1 through 10","1154.79","33698.2","case rate",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","AETNA [1001]","HB CH AETNA HMO / PPO","651.66","58.3","","464.71","67.87","1012.10","221","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","651.66","58.3","","293.04","293.04","293.04","11","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","592.42","53","","983.89","983.89","983.89","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","648.31","58","","677.18","677.18","677.18","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","698.61","62.5","","46.58","46.58","46.58","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","815.97","73","","747.15","747.15","747.15","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.85","44.45","","1141.67","481.21","1141.67","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.85","44.45","","76.54","76.54","76.54","1 through 10","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","WELLPOINT [1015]","HB CH WELLPOINT","870.85","77.91","","273.64","94.28","1367.51","138","496.85","870.85","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.84","59.3","","720.78","230.14","2010.94","427","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","662.84","59.3","","344.45","344.45","344.45","1 through 10","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","876.89","78.45","","1120.13","1120.13","1120.13","1 through 10","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","876.89","78.45","","456.17","105.33","1284.66","242","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","AETNA [1001]","HB CH AETNA HMO / PPO","897.57","58.3","","464.71","67.87","1012.10","221","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","897.57","58.3","","293.04","293.04","293.04","11","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","815.97","53","","983.89","983.89","983.89","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","892.95","58","","677.18","677.18","677.18","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","962.23","62.5","","46.58","46.58","46.58","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1123.89","73","","747.15","747.15","747.15","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.34","44.45","","1141.67","481.21","1141.67","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.34","44.45","","76.54","76.54","76.54","1 through 10","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","WELLPOINT [1015]","HB CH WELLPOINT","1199.48","77.91","","273.64","94.28","1367.51","138","684.34","1199.48","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","912.97","59.3","","720.78","230.14","2010.94","427","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","912.97","59.3","","344.45","344.45","344.45","1 through 10","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1207.79","78.45","","1120.13","1120.13","1120.13","1 through 10","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1207.79","78.45","","456.17","105.33","1284.66","242","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","AETNA [1001]","HB CH AETNA HMO / PPO","1175.19","58.3","","464.71","67.87","1012.10","221","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1175.19","58.3","","293.04","293.04","293.04","11","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1068.35","53","","983.89","983.89","983.89","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1169.14","58","","677.18","677.18","677.18","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1259.85","62.5","","46.58","46.58","46.58","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1471.50","73","","747.15","747.15","747.15","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.01","44.45","","1141.67","481.21","1141.67","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.01","44.45","","76.54","76.54","76.54","1 through 10","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","WELLPOINT [1015]","HB CH WELLPOINT","1570.48","77.91","","273.64","94.28","1367.51","138","896.01","1570.48","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","1195.35","59.3","","720.78","230.14","2010.94","427","1007.88","1581.36","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1195.35","59.3","","344.45","344.45","344.45","1 through 10","1007.88","1581.36","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1581.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1007.88","1581.36","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1581.36","78.45","","456.17","105.33","1284.66","242","1007.88","1581.36","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","AETNA [1001]","HB CH AETNA HMO / PPO","2403.65","58.3","","464.71","67.87","1012.10","221","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2403.65","58.3","","293.04","293.04","293.04","11","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2185.14","53","","983.89","983.89","983.89","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2391.28","58","","677.18","677.18","677.18","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2576.81","62.5","","46.58","46.58","46.58","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3009.72","73","","747.15","747.15","747.15","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.63","44.45","","1141.67","481.21","1141.67","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.63","44.45","","76.54","76.54","76.54","1 through 10","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.90","3092.17","WELLPOINT [1015]","HB CH WELLPOINT","3212.15","77.91","","273.64","94.28","1367.51","138","1832.63","3212.15","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.90","3092.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","2444.88","59.3","","720.78","230.14","2010.94","427","2061.45","3234.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.90","3092.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2444.88","59.3","","344.45","344.45","344.45","1 through 10","2061.45","3234.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.90","3092.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3234.42","78.45","","1120.13","1120.13","1120.13","1 through 10","2061.45","3234.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.90","3092.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3234.42","78.45","","456.17","105.33","1284.66","242","2061.45","3234.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","AETNA [1001]","HB CH AETNA HMO / PPO","1911.73","58.3","","464.71","67.87","1012.10","221","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1911.73","58.3","","293.04","293.04","293.04","11","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1737.94","53","","983.89","983.89","983.89","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1901.90","58","","677.18","677.18","677.18","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2049.46","62.5","","46.58","46.58","46.58","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2393.76","73","","747.15","747.15","747.15","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.57","44.45","","1141.67","481.21","1141.67","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.57","44.45","","76.54","76.54","76.54","1 through 10","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3279.13","2459.35","WELLPOINT [1015]","HB CH WELLPOINT","2554.77","77.91","","273.64","94.28","1367.51","138","1457.57","2554.77","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3279.13","2459.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","1944.52","59.3","","720.78","230.14","2010.94","427","1639.57","2572.48","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3279.13","2459.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1944.52","59.3","","344.45","344.45","344.45","1 through 10","1639.57","2572.48","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3279.13","2459.35","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2572.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1639.57","2572.48","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3279.13","2459.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2572.48","78.45","","456.17","105.33","1284.66","242","1639.57","2572.48","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","AETNA [1001]","HB CH AETNA HMO / PPO","1948.40","58.3","","464.71","67.87","1012.10","221","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1948.40","58.3","","293.04","293.04","293.04","11","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1771.28","53","","983.89","983.89","983.89","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1938.38","58","","677.18","677.18","677.18","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2088.77","62.5","","46.58","46.58","46.58","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2439.68","73","","747.15","747.15","747.15","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1485.53","44.45","","1141.67","481.21","1141.67","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1485.53","44.45","","76.54","76.54","76.54","1 through 10","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","both","","","3342.03","2506.52","WELLPOINT [1015]","HB CH WELLPOINT","2603.78","77.91","","273.64","94.28","1367.51","138","1485.53","2603.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3342.03","2506.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","1981.82","59.3","","720.78","230.14","2010.94","427","1671.02","2621.82","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3342.03","2506.52","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1981.82","59.3","","344.45","344.45","344.45","1 through 10","1671.02","2621.82","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3342.03","2506.52","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2621.82","78.45","","1120.13","1120.13","1120.13","1 through 10","1671.02","2621.82","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3342.03","2506.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2621.82","78.45","","456.17","105.33","1284.66","242","1671.02","2621.82","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","AETNA [1001]","HB CH AETNA HMO / PPO","2057.34","58.3","","464.71","67.87","1012.10","221","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2057.34","58.3","","293.04","293.04","293.04","11","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1870.31","53","","983.89","983.89","983.89","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2046.75","58","","677.18","677.18","677.18","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2205.55","62.5","","46.58","46.58","46.58","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2576.08","73","","747.15","747.15","747.15","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.59","44.45","","1141.67","481.21","1141.67","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.59","44.45","","76.54","76.54","76.54","1 through 10","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.88","2646.66","WELLPOINT [1015]","HB CH WELLPOINT","2749.35","77.91","","273.64","94.28","1367.51","138","1568.59","2749.35","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.88","2646.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2092.63","59.3","","720.78","230.14","2010.94","427","1764.44","2768.41","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.88","2646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2092.63","59.3","","344.45","344.45","344.45","1 through 10","1764.44","2768.41","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.88","2646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2768.41","78.45","","1120.13","1120.13","1120.13","1 through 10","1764.44","2768.41","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.88","2646.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2768.41","78.45","","456.17","105.33","1284.66","242","1764.44","2768.41","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","AETNA [1001]","HB CH AETNA HMO / PPO","1133.28","58.3","","464.71","67.87","1012.10","221","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1133.28","58.3","","293.04","293.04","293.04","11","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1030.26","53","","983.89","983.89","983.89","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1127.45","58","","677.18","677.18","677.18","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1214.93","62.5","","46.58","46.58","46.58","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1419.03","73","","747.15","747.15","747.15","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.05","44.45","","1141.67","481.21","1141.67","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.05","44.45","","76.54","76.54","76.54","1 through 10","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.88","1457.91","WELLPOINT [1015]","HB CH WELLPOINT","1514.48","77.91","","273.64","94.28","1367.51","138","864.05","1514.48","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.88","1457.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1152.72","59.3","","720.78","230.14","2010.94","427","971.94","1524.97","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.88","1457.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1152.72","59.3","","344.45","344.45","344.45","1 through 10","971.94","1524.97","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.88","1457.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1524.97","78.45","","1120.13","1120.13","1120.13","1 through 10","971.94","1524.97","percent of total billed charges",""
"CONDYLAR PLATE 70X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10004149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.88","1457.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1524.97","78.45","","456.17","105.33","1284.66","242","971.94","1524.97","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","AETNA [1001]","HB CH AETNA HMO / PPO","2349.43","58.3","","1530.90","1160.93","1884.08","89","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2135.85","53","","5253.92","5253.92","5253.92","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2337.34","58","","12181.47","12181.47","12181.47","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2518.69","62.5","","1350.68","1350.68","1350.68","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1791.29","44.45","","1910.74","891.94","1910.74","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","WELLPOINT [1015]","HB CH WELLPOINT","3139.70","77.91","","1829.79","1561.50","2617.12","88","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","2389.73","59.3","","1359.46","1201.30","1689.00","61","2014.95","3161.46","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2389.73","59.3","","1718.92","1718.92","1718.92","1 through 10","2014.95","3161.46","percent of total billed charges",""
"CONE TITANIUM 50MM SIZE A COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3161.46","78.45","","1910.74","1019.06","2344.84","74","2014.95","3161.46","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","AETNA [1001]","HB CH AETNA HMO / PPO","2349.43","58.3","","1530.90","1160.93","1884.08","89","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2135.85","53","","5253.92","5253.92","5253.92","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2337.34","58","","12181.47","12181.47","12181.47","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2518.69","62.5","","1350.68","1350.68","1350.68","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1791.29","44.45","","1910.74","891.94","1910.74","1 through 10","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4029.90","3022.42","WELLPOINT [1015]","HB CH WELLPOINT","3139.70","77.91","","1829.79","1561.50","2617.12","88","1791.29","3139.7","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","2389.73","59.3","","1359.46","1201.30","1689.00","61","2014.95","3161.46","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2389.73","59.3","","1718.92","1718.92","1718.92","1 through 10","2014.95","3161.46","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4029.90","3022.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3161.46","78.45","","1910.74","1019.06","2344.84","74","2014.95","3161.46","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","AETNA [1001]","HB CH AETNA HMO / PPO","3688.82","58.3","","1530.90","1160.93","1884.08","89","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3353.47","53","","5253.92","5253.92","5253.92","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3669.83","58","","12181.47","12181.47","12181.47","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3954.56","62.5","","1350.68","1350.68","1350.68","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2812.48","44.45","","1910.74","891.94","1910.74","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","WELLPOINT [1015]","HB CH WELLPOINT","4929.60","77.91","","1829.79","1561.50","2617.12","88","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1359.46","1201.30","1689.00","61","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1718.92","1718.92","1718.92","1 through 10","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4963.77","78.45","","1910.74","1019.06","2344.84","74","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","AETNA [1001]","HB CH AETNA HMO / PPO","3688.82","58.3","","1530.90","1160.93","1884.08","89","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3353.47","53","","5253.92","5253.92","5253.92","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3669.83","58","","12181.47","12181.47","12181.47","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3954.56","62.5","","1350.68","1350.68","1350.68","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2812.48","44.45","","1910.74","891.94","1910.74","1 through 10","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","WELLPOINT [1015]","HB CH WELLPOINT","4929.60","77.91","","1829.79","1561.50","2617.12","88","2812.48","4929.6","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1359.46","1201.30","1689.00","61","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1718.92","1718.92","1718.92","1 through 10","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4963.77","78.45","","1910.74","1019.06","2344.84","74","3163.65","4963.77","percent of total billed charges",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","both","","","8940.00","6705.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","3835.26","6526.2","per diem",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","outpatient","","","8940.00","6705.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7013.43","78.45","","4705.83","4705.83","4705.83","1 through 10","7013.43","7013.43","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","AETNA [1001]","HB CH AETNA HMO / PPO","2527.89","58.3","","2343.98","2343.98","2343.98","1 through 10","1860.14","3888.77","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","1860.14","3888.77","other","Multiple Surgery"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1860.14","3888.77","other","OPPS APC"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1860.14","3888.77","per diem",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","1909.08","3899.16","1 through 10","1873.9","3401.59","other","ASC "
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","1952.28","3904.56","1 through 10","1873.9","3401.59","other","ASC "
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2571.25","59.3","","7197.25","3586.91","7197.25","1 through 10","1873.9","3401.59","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14982.24","14982.24","15958.16","1 through 10","1873.9","3401.59","other","Multiple Surgery"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3401.59","78.45","","4589.74","1883.45","4589.74","1 through 10","1873.9","3401.59","percent of total billed charges",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","37458.03","28093.52","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","10987.52","","Case rate ($10,987.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,265.50, add-ons for qualifying new technology services are included. If operating cost exceeds $55,407.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,705.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,223.87. The transfer operating threshold is the transfer adjustment factor * $10,265.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.65. The transfer capital threshold is the transfer adjustment factor * $763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9983.24","9983.24","9983.24","1 through 10","9793.11","11448.4953","other","Inpatient DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","37458.03","28093.52","MEDICARE [2001]","HB NWH MEDICARE","10987.52","","Case rate ($10,987.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,265.50, add-ons for qualifying new technology services are included. If operating cost exceeds $55,407.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,705.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,223.87. The transfer operating threshold is the transfer adjustment factor * $10,265.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.65. The transfer capital threshold is the transfer adjustment factor * $763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11049.28","11049.13","11069.15","1 through 10","9793.11","11448.4953","other","Inpatient DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","37458.03","28093.52","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9793.11","","Case rate ($9,992.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,265.50, add-ons for qualifying new technology services are included. If operating cost exceeds $55,407.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,705.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,229.32. The transfer operating threshold is the transfer adjustment factor * $10,265.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.65. The transfer capital threshold is the transfer adjustment factor * $763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9868.15","9868.15","9868.15","1 through 10","9793.11","11448.4953","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","36885.28","27663.96","MEDICARE [2001]","HB NWH MEDICARE","23641.18","","Case rate ($23,641.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,087.64, add-ons for qualifying new technology services are included. If operating cost exceeds $67,229.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,585.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,998.07. The transfer operating threshold is the transfer adjustment factor * $22,087.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,643.10. The transfer capital threshold is the transfer adjustment factor * $1,643.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24117.15","24116.84","24160.51","1 through 10","21071.24","24988.5141","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","36885.28","27663.96","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","21071.24","","Case rate ($21,501.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,087.64, add-ons for qualifying new technology services are included. If operating cost exceeds $67,229.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,585.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,858.16. The transfer operating threshold is the transfer adjustment factor * $22,087.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,643.10. The transfer capital threshold is the transfer adjustment factor * $1,643.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21574.09","21574.09","21574.09","1 through 10","21071.24","24988.5141","other","Inpatient DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","25831.10","19373.32","MEDICARE [2001]","HB NWH MEDICARE","7244.78","","Case rate ($7,244.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,442.36, add-ons for qualifying new technology services are included. If operating cost exceeds $52,584.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,495.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,691.14. The transfer operating threshold is the transfer adjustment factor * $7,442.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.64. The transfer capital threshold is the transfer adjustment factor * $553.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7134.67","7134.67","7134.67","1 through 10","7099.88","7462.12","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","66569.11","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12661.2618","","Fee schedule rate ($31,267.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12661.2618","31267.20","31267.20","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MINOR","346","DRG","","","","","","","","inpatient","","","20828.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15547.59","","Standard inlier is a Case rate ($15,547.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,206.92) for the length of stay and the standard reimbursement.","15547.59","15547.59","15547.59","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19273.69","","Standard inlier is a Case rate ($19,273.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,419, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,735.98) for the length of stay and the standard reimbursement.","18397.86","18397.86","18397.86","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20703.79","","Standard inlier is a Case rate ($20,703.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,419, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,938.82) for the length of stay and the standard reimbursement.","20703.79","20703.79","20703.79","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13294.2601","","Fee schedule rate ($18,604.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13294.2601","18604.56","18604.56","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","18604.58","","Fee schedule rate ($18,604.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18604.58","18604.58","18604.58","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","MASSHEALTH [3001]","HB NWH MEDICAID","8999.56","","Case rate ($9,695.60). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,125.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,643.32 and the sum of the standard inlier and any outlier amount.","2059.44","2059.44","2059.44","1 through 10","7112.37","140809.55","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","33530.93","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","8999.56","","Case rate ($9,695.60). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,125.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,643.32 and the sum of the standard inlier and any outlier amount.","4118.87","4118.87","4118.87","1 through 10","7112.37","140809.55","case rate",""
"CONNECTOR 4.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10188928","CDM","C1763","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","AETNA [1001]","HB CH AETNA HMO / PPO","2520.02","58.3","","416.75","416.75","416.75","1 through 10","1921.35","3367.66","percent of total billed charges",""
"CONNECTOR 4.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10188928","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2563.24","59.3","","7893.60","423.68","7893.60","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR 4.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10188928","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3391.00","78.45","","555.84","329.40","555.84","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","464.71","67.87","1012.10","221","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","778.31","58.3","","293.04","293.04","293.04","11","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","707.55","53","","983.89","983.89","983.89","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","677.18","677.18","677.18","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","46.58","46.58","46.58","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","747.15","747.15","747.15","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","1141.67","481.21","1141.67","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","76.54","76.54","76.54","1 through 10","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","273.64","94.28","1367.51","138","593.41","1040.1","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","720.78","230.14","2010.94","427","667.5","1047.31","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","791.66","59.3","","344.45","344.45","344.45","1 through 10","667.5","1047.31","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1120.13","1120.13","1120.13","1 through 10","667.5","1047.31","percent of total billed charges",""
"CONNECTOR CROSS 55MM MULTIAXIAL","SUP-ITM-10131849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","456.17","105.33","1284.66","242","667.5","1047.31","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","AETNA [1001]","HB CH AETNA HMO / PPO","2520.02","58.3","","416.75","416.75","416.75","1 through 10","1921.35","3367.66","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2563.24","59.3","","7893.60","423.68","7893.60","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3391.00","78.45","","555.84","329.40","555.84","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","AETNA [1001]","HB CH AETNA HMO / PPO","2520.02","58.3","","416.75","416.75","416.75","1 through 10","1921.35","3367.66","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2563.24","59.3","","7893.60","423.68","7893.60","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3391.00","78.45","","555.84","329.40","555.84","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR REPAIR 10X3.0MM NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10124173","CDM","C1763","HCPCS","0278","RC","","","","both","","","3513.00","2634.75","AETNA [1001]","HB CH AETNA HMO / PPO","2048.08","58.3","","416.75","416.75","416.75","1 through 10","1561.53","2736.98","percent of total billed charges",""
"CONNECTOR REPAIR 10X3.0MM NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10124173","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3513.00","2634.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2083.21","59.3","","7893.60","423.68","7893.60","1 through 10","1756.5","2755.95","percent of total billed charges",""
"CONNECTOR REPAIR 10X3.0MM NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10124173","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3513.00","2634.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2755.95","78.45","","555.84","329.40","555.84","1 through 10","1756.5","2755.95","percent of total billed charges",""
"Consult Path Surgery","PX-31000034","CDM","88329","CPT","0312","RC","","","","both","","","116.00","87.00","AETNA [1001]","HB CH AETNA HMO / PPO","67.63","58.3","","64.07","64.07","64.07","1 through 10","51.56","170.56","percent of total billed charges",""
"Consult Path Surgery Cyto Ea Addl","PX-31000037","CDM","88334","CPT","0312","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","66.34","66.34","66.34","1 through 10","53.34","93.49","percent of total billed charges",""
"Consult Path Surgery Cyto Ea Addl","PX-31000037","CDM","88334","CPT","0312","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","90.84","90.84","90.84","1 through 10","53.34","93.49","percent of total billed charges",""
"Consult Path Surgery Cyto Ea Addl","PX-31000037","CDM","88334","CPT","0312","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","89.95","89.95","1 through 10","60","94.14","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","both","","","261.00","195.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","190.53","73","","144.02","144.02","144.02","1 through 10","116.01","2963.62","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","both","","","261.00","195.75","WELLPOINT [1015]","HB CH WELLPOINT","203.35","77.91","","400.10","400.10","400.10","1 through 10","116.01","2963.62","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","outpatient","","","261.00","195.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","154.77","59.3","","148.84","140.94","148.84","1 through 10","125.76","1886.45","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","204.75","78.45","","195.28","195.28","195.28","1 through 10","125.76","1886.45","percent of total billed charges",""
"Consult Path Surgery Ea Add","PX-31000035","CDM","88332","CPT","0312","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","94.56","94.56","1 through 10","56.01","98.85","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","287.00","215.25","AETNA [1001]","HB CH AETNA HMO / PPO","167.32","58.3","","316.38","316.38","316.38","1 through 10","127.57","768.52","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","287.00","215.25","WELLPOINT [1015]","HB CH WELLPOINT","223.60","77.91","","219.74","215.93","219.74","1 through 10","127.57","768.52","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","319.18","163.49","789.92","1 through 10","125.76","489.19","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.15","78.45","","214.50","214.50","214.50","18","125.76","489.19","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","AETNA [1001]","HB CH AETNA HMO / PPO","10.03","58.3","","0.44","0.31","0.46","18007","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.12","53","","16.38","16.38","16.38","1 through 10","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","12.56","73","","23.10","23.10","23.10","1 through 10","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","17.20","12.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","12.14","70.6","","0.30","0.30","0.30","76","7.65","12.14","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","17.20","12.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.98","52.2","","0.40","0.04","0.55","458","8.6","8.98","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","AETNA [1001]","HB CH AETNA HMO / PPO","5.01","58.3","","0.44","0.31","0.46","18007","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4.56","53","","16.38","16.38","16.38","1 through 10","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6.28","73","","23.10","23.10","23.10","1 through 10","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","8.60","6.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6.07","70.6","","0.30","0.30","0.30","76","3.82","6.07","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","8.60","6.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","4.49","52.2","","0.40","0.04","0.55","458","4.3","4.49","percent of total billed charges",""
"Control Hemorr Oropharyngeal Smp","PX-75000069","CDM","42960","CPT","0761","RC","","","","both","","","809.00","606.75","AETNA [1001]","HB CH AETNA HMO / PPO","471.65","58.3","","4687.96","3384.99","4687.96","1 through 10","347.06","630.29","percent of total billed charges",""
"Control Hemorr Oropharyngeal Smp","PX-75000069","CDM","42960","CPT","0761","RC","","","","both","","","809.00","606.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","5631.00","5631.00","5631.00","1 through 10","347.06","630.29","per diem",""
"Control Hemorr Oropharyngeal Smp","PX-75000069","CDM","42960","CPT","0761","RC","","","","outpatient","","","809.00","606.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.74","59.3","","6191.68","6191.68","6191.68","1 through 10","323.6","634.66","percent of total billed charges",""
"Control Nosebleed Ant Cplx|BILATERAL PROCEDURE","PX-76000749","CDM","30903","CPT","0761","RC","","","50","outpatient","","","381.00","285.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","182.66","","Case rate ($182.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","258.65","258.65","258.65","1 through 10","182.66","599.39","other","ASC "
"Control Nosebleed Ant Smp|BILATERAL PROCEDURE","PX-76000748","CDM","30901","CPT","0761","RC","","","50","outpatient","","","289.00","216.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","182.66","","Case rate ($182.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","129.14","129.14","129.14","1 through 10","182.66","599.39","other","ASC "
"Control Nosebleed Posterior Initial","PX-76000750","CDM","30905","CPT","0761","RC","","","","both","","","478.00","358.50","MEDICARE [2001]","HB NWH MEDICARE","134.67","","APC Price ($134.67). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","106.48","372.41","other","OPPS APC"
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MAJOR","384","DRG","","","","","","","","inpatient","","","24368.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25910.02","","Standard inlier is a Case rate ($25,910.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,391, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,677.82) for the length of stay and the standard reimbursement.","25910.02","25910.02","25910.02","1 through 10","4127.37","32024.74","case rate",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MAJOR","384","DRG","","","","","","","","inpatient","","","24368.36","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23860.60","","Fee schedule rate ($23,860.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23860.60","23860.60","23860.60","1 through 10","4127.37","32024.74","case rate",""
"Conv Ext Bil Drg Cath to Int-Ext Bil Drg Cath","PX-36000378","CDM","47535","CPT","0361","RC","","","","both","","","1111.00","833.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4109.15","4109.15","4109.15","1 through 10","476.62","9590.18","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB CH AETNA HMO / PPO","39.64","58.3","","37.42","37.42","37.42","1 through 10","21.25","170.56","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","MEDICARE [2001]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","23.51","211.62","26","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","23.04","23.04","207.39","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","65.43","65.43","65.43","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","68.00","51.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","40.32","59.3","","38.68","38.68","38.68","1 through 10","5.55","108.57","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","53.35","78.45","","50.74","30.07","50.74","1 through 10","5.55","108.57","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","45.71","1 through 10","5.9","489.19","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","20.49","768.52","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","outpatient","","","175.00","131.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.78","59.3","","99.62","99.62","99.62","1 through 10","5.34","489.19","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","130.70","130.70","130.70","1 through 10","5.34","489.19","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","22","12.16","97.85","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB NWH TRICARE","97.85","95","","14.95","14.95","14.95","1 through 10","12.16","97.85","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","44.45","","44.90","44.90","44.90","1 through 10","12.16","97.85","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","58.60","12","12.8","80.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","39.76","76.88","1 through 10","12.8","80.8","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","2864.00","2148.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1237.95","2231.34","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","2864.00","2148.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3206.29","3206.29","3206.29","1 through 10","1237.95","2231.34","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","2864.00","2148.00","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","5772.39","15","1237.95","2231.34","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","2864.00","2148.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1893.45","5679.15","1 through 10","1237.95","2231.34","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","2864.00","2148.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1886.05","1741.52","1886.05","1 through 10","1237.95","2231.34","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","2864.00","2148.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1599.32","","Case rate ($1,599.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2309.42","2309.42","2309.42","1 through 10","1237.95","2246.81","other","ASC "
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","2864.00","2148.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1599.32","","Case rate ($1,599.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2312.62","2264.64","2312.62","1 through 10","1237.95","2246.81","other","ASC "
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","2864.00","2148.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1698.35","59.3","","4896.23","4896.23","4896.23","16","1237.95","2246.81","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","2864.00","2148.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","5595.54","8727.54","1 through 10","1237.95","2246.81","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","2864.00","2148.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","9173.22","9173.22","9173.22","1 through 10","1237.95","2246.81","other","Multiple Surgery"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","174401.02","130800.76","MEDICARE [2001]","HB NWH MEDICARE","41223.69","","Case rate ($41,223.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $38,514.75, add-ons for qualifying new technology services are included. If operating cost exceeds $83,657.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,807.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $38,358.57. The transfer operating threshold is the transfer adjustment factor * $38,514.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,865.12. The transfer capital threshold is the transfer adjustment factor * $2,865.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40725.52","40725.52","40725.52","1 through 10","36742.42","42121.2066","other","Inpatient DRG"
"Correct Hammertoe","PX-76000642","CDM","28285","CPT","0761","RC","","","","both","","","5661.00","4245.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","4250.12","","APC Price ($4,126.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3964.91","3964.91","3964.91","1 through 10","2361.01","4410.49","other","OPPS APC"
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","16.38","98.61","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.67","44.45","","71.50","71.50","71.50","1 through 10","16.38","98.61","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","71.50","93.00","1 through 10","17.23","105.33","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","190.00","142.50","AETNA [1001]","HB CH AETNA HMO / PPO","110.77","58.3","","104.90","104.90","104.90","42","15.97","180.5","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","190.00","142.50","TRICARE [160005]","HB NWH TRICARE","180.50","95","","18.66","18.66","19.64","1 through 10","15.97","180.5","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.46","44.45","","142.23","136.49","142.23","1 through 10","15.97","180.5","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","190.00","142.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.67","59.3","","108.41","108.41","115.61","34","16.81","149.06","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","142.23","84.29","142.23","38","16.81","149.06","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0510","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB CH AETNA HMO / PPO","124.18","58.3","","146.29","146.29","146.29","33","124.18","124.18","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","outpatient","","","213.00","159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.31","59.3","","151.19","151.19","577.80","30","80.01","167.1","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","198.35","117.54","198.35","15","80.01","167.1","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","AETNA [1001]","HB CH AETNA HMO / PPO","398.60","58.3","","464.71","67.87","1012.10","221","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","398.60","58.3","","293.04","293.04","293.04","11","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.36","53","","983.89","983.89","983.89","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","396.55","58","","677.18","677.18","677.18","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","427.31","62.5","","46.58","46.58","46.58","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.10","73","","747.15","747.15","747.15","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","303.90","44.45","","1141.67","481.21","1141.67","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","303.90","44.45","","76.54","76.54","76.54","1 through 10","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.70","512.77","WELLPOINT [1015]","HB CH WELLPOINT","532.67","77.91","","273.64","94.28","1367.51","138","303.9","532.67","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.70","512.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","405.43","59.3","","720.78","230.14","2010.94","427","341.85","536.36","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.70","512.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","405.43","59.3","","344.45","344.45","344.45","1 through 10","341.85","536.36","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.70","512.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","536.36","78.45","","1120.13","1120.13","1120.13","1 through 10","341.85","536.36","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.70","512.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","536.36","78.45","","456.17","105.33","1284.66","242","341.85","536.36","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","AETNA [1001]","HB CH AETNA HMO / PPO","1364.22","58.3","","1530.90","1160.93","1884.08","89","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.20","53","","5253.92","5253.92","5253.92","1 through 10","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1357.20","58","","12181.47","12181.47","12181.47","1 through 10","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1462.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.13","44.45","","1910.74","891.94","1910.74","1 through 10","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","WELLPOINT [1015]","HB CH WELLPOINT","1823.09","77.91","","1829.79","1561.50","2617.12","88","1040.13","1823.09","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.62","59.3","","1359.46","1201.30","1689.00","61","1170","1835.73","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1387.62","59.3","","1718.92","1718.92","1718.92","1 through 10","1170","1835.73","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.73","78.45","","1910.74","1019.06","2344.84","74","1170","1835.73","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","AETNA [1001]","HB CH AETNA HMO / PPO","638.39","58.3","","464.71","67.87","1012.10","221","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","638.39","58.3","","293.04","293.04","293.04","11","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","580.35","53","","983.89","983.89","983.89","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","635.10","58","","677.18","677.18","677.18","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","684.38","62.5","","46.58","46.58","46.58","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","747.15","747.15","747.15","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","1141.67","481.21","1141.67","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","76.54","76.54","76.54","1 through 10","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","WELLPOINT [1015]","HB CH WELLPOINT","853.11","77.91","","273.64","94.28","1367.51","138","486.73","853.11","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","720.78","230.14","2010.94","427","547.5","859.03","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","649.34","59.3","","344.45","344.45","344.45","1 through 10","547.5","859.03","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","1120.13","1120.13","1120.13","1 through 10","547.5","859.03","percent of total billed charges",""
"COVER BONE 1 HOLE TI ASSAY","SUP-ITM-10140289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","456.17","105.33","1284.66","242","547.5","859.03","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","498.00","373.50","AETNA [1001]","HB CH AETNA HMO / PPO","290.33","58.3","","274.43","274.43","274.43","1 through 10","221.36","745.32","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","236.68","","APC Price ($241.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","241.54","241.54","241.54","1 through 10","221.36","745.32","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","498.00","373.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","295.31","59.3","","283.62","283.62","283.62","1 through 10","249","473.25","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","390.68","78.45","","220.51","220.51","220.51","1 through 10","249","473.25","percent of total billed charges",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","36947.29","27710.47","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11383.81","11383.81","11383.81","1 through 10","13621.55","16468.14","case rate",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","36947.29","27710.47","MEDICARE [2001]","HB NWH MEDICARE","13899.54","","Case rate ($13,899.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,278.60, add-ons for qualifying new technology services are included. If operating cost exceeds $59,420.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,837.35. The transfer operating threshold is the transfer adjustment factor * $14,278.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.19. The transfer capital threshold is the transfer adjustment factor * $1,062.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14751.48","14751.28","14777.98","1 through 10","13621.55","16468.14","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","36947.29","27710.47","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13621.55","","Case rate ($13,899.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,278.60, add-ons for qualifying new technology services are included. If operating cost exceeds $59,420.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,004.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,837.35. The transfer operating threshold is the transfer adjustment factor * $14,278.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.19. The transfer capital threshold is the transfer adjustment factor * $1,062.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13212.09","1248.13","14897.70","1 through 10","13621.55","16468.14","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","25281.87","18961.40","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9198.70","","Case rate ($8,930.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,174.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,248.29. The transfer operating threshold is the transfer adjustment factor * $9,174.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.48. The transfer capital threshold is the transfer adjustment factor * $682.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9352.24","7155.95","13853.30","1 through 10","8752.16","10581.16","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","25281.87","18961.40","HUMANA [1012]","HB NWH MEDICARE","8930.78","","Case rate ($8,930.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,174.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,248.29. The transfer operating threshold is the transfer adjustment factor * $9,174.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.48. The transfer capital threshold is the transfer adjustment factor * $682.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6122.61","6122.61","6122.61","1 through 10","8752.16","10581.16","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","25281.87","18961.40","MEDICARE [2001]","HB NWH MEDICARE","8930.78","","Case rate ($8,930.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,174.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,248.29. The transfer operating threshold is the transfer adjustment factor * $9,174.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.48. The transfer capital threshold is the transfer adjustment factor * $682.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9948.84","952.43","9966.74","18","8752.16","10581.16","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","25281.87","18961.40","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8752.16","","Case rate ($8,930.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,174.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,248.29. The transfer operating threshold is the transfer adjustment factor * $9,174.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.48. The transfer capital threshold is the transfer adjustment factor * $682.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8889.34","8889.34","8889.34","1 through 10","8752.16","10581.16","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","25281.87","18961.40","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","8752.16","","Case rate ($8,930.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,174.33, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,248.29. The transfer operating threshold is the transfer adjustment factor * $9,174.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.48. The transfer capital threshold is the transfer adjustment factor * $682.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10042.37","10042.37","10042.37","1 through 10","8752.16","10581.16","other","Inpatient DRG"
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","AETNA [1001]","HB CH AETNA HMO / PPO","493.11","58.3","","464.71","67.87","1012.10","221","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","493.11","58.3","","293.04","293.04","293.04","11","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","448.28","53","","983.89","983.89","983.89","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","490.58","58","","677.18","677.18","677.18","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","528.64","62.5","","46.58","46.58","46.58","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","617.45","73","","747.15","747.15","747.15","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.97","44.45","","1141.67","481.21","1141.67","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.97","44.45","","76.54","76.54","76.54","1 through 10","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","845.82","634.36","WELLPOINT [1015]","HB CH WELLPOINT","658.98","77.91","","273.64","94.28","1367.51","138","375.97","658.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","845.82","634.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","501.57","59.3","","720.78","230.14","2010.94","427","422.91","663.55","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","845.82","634.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","501.57","59.3","","344.45","344.45","344.45","1 through 10","422.91","663.55","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","845.82","634.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","663.55","78.45","","1120.13","1120.13","1120.13","1 through 10","422.91","663.55","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","845.82","634.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","663.55","78.45","","456.17","105.33","1284.66","242","422.91","663.55","percent of total billed charges",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","39445.33","29584.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","26399.12","","Case rate ($26,937.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $27,672.52, add-ons for qualifying new technology services are included. If operating cost exceeds $72,814.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,000.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $24,879.31. The transfer operating threshold is the transfer adjustment factor * $27,672.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,058.57. The transfer capital threshold is the transfer adjustment factor * $2,058.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17381.73","17381.73","17381.73","1 through 10","26399.12","30246.4954","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","71606.81","53705.11","MEDICARE [2001]","HB NWH MEDICARE","43312.79","","Case rate ($43,312.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,466.56, add-ons for qualifying new technology services are included. If operating cost exceeds $85,608.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,952.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $40,302.47. The transfer operating threshold is the transfer adjustment factor * $40,466.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,010.32. The transfer capital threshold is the transfer adjustment factor * $3,010.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","42684.38","42684.38","42684.38","1 through 10","38604.43","44226.5747","other","Inpatient DRG"
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","464.71","67.87","1012.10","221","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","293.04","293.04","293.04","11","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","983.89","983.89","983.89","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","677.18","677.18","677.18","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","46.58","46.58","46.58","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","747.15","747.15","747.15","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1141.67","481.21","1141.67","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","76.54","76.54","76.54","1 through 10","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","273.64","94.28","1367.51","138","1233.49","2162","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","720.78","230.14","2010.94","427","1387.5","2176.99","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1645.58","59.3","","344.45","344.45","344.45","1 through 10","1387.5","2176.99","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1387.5","2176.99","percent of total billed charges",""
"CRANIUM PLATE 7MM HALF ALTA TITANIUM","SUP-ITM-10104668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","456.17","105.33","1284.66","242","1387.5","2176.99","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","109","6.38","57","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","42.34","42.34","42.34","1 through 10","6.38","57","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","32.89","3.76","32.89","1 through 10","6.38","57","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","TRICARE [160005]","HB NWH TRICARE","57.00","95","","7.84","7.45","7.84","1 through 10","6.38","57","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","26.42","26.42","44.59","1 through 10","6.38","57","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","137","6.71","47.07","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.18","33.18","33.18","1 through 10","6.71","47.07","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","42.46","42.46","42.46","1 through 10","6.71","47.07","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","103","6.71","47.07","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","73","5.02","41.8","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","CHAMPVA [160001]","HB NWH TRICARE","41.80","95","","6.17","6.17","6.17","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","TRICARE [160005]","HB NWH TRICARE","41.80","95","","6.17","6.17","6.17","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","33.06","33.06","33.06","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","63","5.29","34.52","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","65","5.29","34.52","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","73","5.02","41.8","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","CHAMPVA [160001]","HB NWH TRICARE","41.80","95","","6.17","6.17","6.17","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","TRICARE [160005]","HB NWH TRICARE","41.80","95","","6.17","6.17","6.17","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","33.06","33.06","33.06","1 through 10","5.02","41.8","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","63","5.29","34.52","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","65","5.29","34.52","percent of total billed charges",""
"Creatinine Clearance","PX-30000396","CDM","82575","CPT","0301","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","1 through 10","9.27","71.25","percent of total billed charges",""
"Creatinine Clearance","PX-30000396","CDM","82575","CPT","0301","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","42.78","1 through 10","9.74","59.6","percent of total billed charges",""
"Creatinine Clearance","PX-30000396","CDM","82575","CPT","0301","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","56.12","56.12","1 through 10","9.74","59.6","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0300","RC","","","","inpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.16","56","","34.57","34.57","34.57","1 through 10","34.16","43.07","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","356","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","CHAMPVA [160001]","HB NWH TRICARE","57.95","95","","6.24","6.24","6.24","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","43.07","43.07","43.07","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.33","53","","16.96","16.96","16.96","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","33.45","5.08","48.45","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","TRICARE [160005]","HB NWH TRICARE","57.95","95","","6.24","5.93","130.48","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","45.36","26.88","45.36","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","26.88","26.88","26.88","1 through 10","5.08","57.95","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","34.58","349","5.34","47.85","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","36.17","59.3","","33.75","33.75","33.75","1 through 10","5.34","47.85","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","268","5.34","47.85","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","3127.00","2345.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1566.63","50.1","","881.04","881.04","881.04","1 through 10","695.29","2453.13","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","both","","","1864.00","1398.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1081.12","58","","338.33","338.33","338.33","1 through 10","828.55","1452.24","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","both","","","217.00","162.75","AETNA [1001]","HB CH AETNA HMO / PPO","126.51","58.3","","119.64","119.64","119.64","1 through 10","96.46","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","AETNA [1001]","HB CH AETNA HMO / PPO","127.68","58.3","","120.77","120.77","120.77","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","209.58","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","209.41","209.41","209.41","1 through 10","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","203.50","122","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","159.87","73","","233.49","116.74","233.49","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","598.29","99.72","598.29","52","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","49.86","49.86","199.43","1 through 10","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","WELLPOINT [1015]","HB CH WELLPOINT","170.62","77.91","","167.76","167.76","167.76","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","outpatient","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.81","78.45","","163.76","97.04","327.51","1 through 10","96.51","489.19","percent of total billed charges",""
"Cryofibrinogen","PX-30000397","CDM","82585","CPT","0301","RC","","","","both","","","69.00","51.75","AETNA [1001]","HB CH AETNA HMO / PPO","40.23","58.3","","37.99","37.99","37.99","1 through 10","13.86","75.08","percent of total billed charges",""
"Cryofibrinogen","PX-30000397","CDM","82585","CPT","0301","RC","","","","outpatient","","","69.00","51.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","40.92","59.3","","39.26","39.26","39.26","1 through 10","5.98","54.13","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","both","","","58.00","43.50","AETNA [1001]","HB CH AETNA HMO / PPO","33.81","58.3","","31.75","31.75","31.75","1 through 10","6.34","55.1","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","58.00","43.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.39","59.3","","32.82","32.82","32.82","1 through 10","6.67","45.5","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","1 through 10","7.18","57.95","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","122.89","34.57","122.89","1 through 10","7.38","47.85","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","1 through 10","7.38","47.85","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","FALLON HEALTH [1008]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.73","419.73","419.73","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","1539.12","1099.76","1539.12","1 through 10","265.02","2689.32","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","418.17","419.02","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","110","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","888.53","888.53","888.53","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1045.33","1045.33","1045.33","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1151.93","1151.93","1151.93","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","265.02","2689.32","other","Tricare OPPS"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","413.01","418.43","14","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","424.11","424.11","424.11","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","417.33","14","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","11","385.88","1842","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","18","385.88","1842","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","2639.43","1 through 10","385.88","1842","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","1842","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1309.29","35.54","","1631.96","845.08","1631.96","1 through 10","385.88","1842","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","12","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","631.73","657.10","1 through 10","225.91","1072.75","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","533.08","578.71","1 through 10","225.91","1072.75","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","102","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","327.91","327.91","327.91","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","385.78","374.61","385.78","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","425.12","412.81","425.12","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MOLINA [1014]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","281.32","284.12","16","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","281.32","286.32","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","27","230.56","1016.85","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","78","230.56","1016.85","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","28","230.56","1016.85","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","1060.58","1 through 10","230.56","1016.85","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","520.31","35.54","","648.77","495.98","1048.73","1 through 10","230.56","1016.85","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","18","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","2201.68","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","929.97","968.56","1 through 10","385.88","2201.68","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","419.87","419.87","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","424.11","125","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","788.92","788.92","788.92","1 through 10","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","928.14","928.14","928.14","1 through 10","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1022.79","1022.79","1022.79","13","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","417.13","420.63","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1071.89","35.54","","1021.56","1021.56","1021.56","1 through 10","385.88","2201.68","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.63","415.63","420.63","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1663.01","1663.01","1663.01","1 through 10","385.88","1604.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","17","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","868.13","968.56","1 through 10","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1071.89","35.54","","1021.56","1021.56","1336.27","1 through 10","385.88","1604.27","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0350","RC","","","","inpatient","","","2339.00","1754.25","AETNA [1001]","HB CH AETNA HMO / PPO","1363.64","58.3","","1289.36","1289.36","1289.36","1 through 10","1309.84","1651.33","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0350","RC","","","","inpatient","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1651.33","70.6","","1748.25","1036.03","1748.25","1 through 10","1309.84","1651.33","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","38","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","FALLON HEALTH [1008]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","265.02","1730.92","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","653.73","968.56","28","265.02","1730.92","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","380","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","698.58","698.58","698.58","1 through 10","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","821.86","821.86","1643.72","43","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","862.96","813.48","862.96","1 through 10","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","905.67","905.67","2717.01","83","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MOLINA [1014]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","841.43","841.43","841.43","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1707.47","73","","1245.31","1245.31","1245.31","1 through 10","265.02","1730.92","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","265.02","1730.92","other","Tricare OPPS"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","415.63","1246.89","57","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","839.46","424.11","839.46","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.28","35.54","","792.03","792.03","1036.03","1 through 10","265.02","1730.92","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.34","415.63","420.63","30","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.28","35.54","","1036.03","1036.03","1036.03","1 through 10","265.02","1730.92","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1289.36","982.57","2578.72","1 through 10","385.88","1604.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","2639.43","146","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","2766.75","47","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","831.28","35.54","","792.03","792.03","792.03","1 through 10","385.88","1604.27","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.28","35.54","","792.03","792.03","1748.25","54","385.88","1604.27","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","506.37","506.37","1 through 10","200.84","2571.06","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","19","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1761","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1761","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1761","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","506.37","506.37","506.37","1 through 10","201.74","1761","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","464.00","464.00","464.00","1 through 10","201.74","1761","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1251.72","35.54","","1560.43","1192.93","1560.43","1 through 10","201.74","1761","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","16","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","554.42","554.42","554.42","1 through 10","200.84","1656.37","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","208.03","209.98","1 through 10","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1134.5","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","15","201.74","1134.5","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1134.5","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","1134.5","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","806.40","35.54","","768.35","768.35","1005.05","1 through 10","201.74","1134.5","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","16","112.51","1347.58","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1347.58","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","340.56","340.56","1 through 10","112.51","923","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","340.56","340.56","1 through 10","112.51","923","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","923","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","923","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","656.07","35.54","","625.20","625.20","817.80","1 through 10","112.51","923","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","33","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","FALLON HEALTH [1008]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1264.89","424.11","1272.33","1 through 10","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","758.54","758.54","758.54","1 through 10","201.74","3015.63","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","552.77","758.54","1 through 10","201.74","3015.63","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","486.19","506.37","19","201.74","3015.63","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.63","419.02","420.63","1 through 10","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","MARTIN'S POINT [160007]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","316","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","MOLINA [1014]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","841.43","841.43","841.43","1 through 10","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","201.74","3015.63","other","Tricare OPPS"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","420.63","43","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1468.16","35.54","","1399.12","1399.12","1399.12","1 through 10","201.74","3015.63","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","200.53","420.63","35","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","4131.00","3098.25","WELLSENSE NH [1050]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","419.02","419.02","1 through 10","201.74","3015.63","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2277.64","2277.64","2277.64","1 through 10","201.74","2065.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","77","201.74","2065.5","other","Multiple Imaging"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","220","201.74","2065.5","other","Multiple Imaging"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","3219.79","68","201.74","2065.5","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","574.96","19","201.74","2065.5","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","464.00","464.00","464.00","1 through 10","201.74","2065.5","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","1399.12","1399.12","1399.12","1 through 10","201.74","2065.5","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","4131.00","3098.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1468.16","35.54","","1399.12","1399.12","1830.15","36","201.74","2065.5","percent of total billed charges",""
"CT Angio Hrt W/3d Image|REDUCED SERVICES","PX-35000082","CDM","75574","CPT","0352","RC","","","52","both","","","4131.00","3098.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.06","212.06","212.06","1 through 10","402.91","436.79","other","OPPS APC"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2310.00","1732.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","1168.07","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","253.73","124.27","253.73","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","CHAMPVA [160001]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1420.58","other","Tricare OPPS"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1420.58","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","252.58","26","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","314.64","305.03","629.28","1 through 10","112.51","1420.58","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","346.73","344.06","346.73","1 through 10","112.51","1420.58","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.37","126.29","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","340.56","1 through 10","112.51","973","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","13","112.51","973","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","973","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","973","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.61","35.54","","862.00","862.00","862.00","1 through 10","112.51","973","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1283.00","962.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","642.78","50.1","","248.00","248.00","248.00","1 through 10","550.41","1873.9","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","895.00","671.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","653.35","73","","739.50","739.50","739.50","1 through 10","318.08","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","895.00","671.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","318.08","35.54","","303.02","303.02","303.02","1 through 10","318.08","447.5","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","200.53","516.73","1 through 10","200.84","1736.67","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.39","207.39","207.39","1 through 10","200.84","1736.67","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1189.5","other","Multiple Imaging"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1189.5","other","Multiple Imaging"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","516.73","1 through 10","200.84","1355.61","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","208.03","506.40","1 through 10","200.84","1355.61","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","207.19","207.19","1 through 10","200.84","1355.61","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","1857.00","1392.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","986.89","other","Multiple Imaging"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","1857.00","1392.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","511.00","1 through 10","201.74","986.89","other","Multiple Imaging"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","1857.00","1392.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","986.89","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","450.05","1 through 10","112.51","1076.75","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","266.67","167","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","212.87","212.87","212.87","1 through 10","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","500.87","243.19","500.87","1 through 10","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","275.97","275.97","275.97","17","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MOLINA [1014]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1076.75","73","","813.08","813.08","813.08","1 through 10","112.51","1076.75","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","1306.70","20","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","516.73","516.73","516.73","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","261.34","18","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","813.08","813.08","813.08","1 through 10","112.51","737.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","142.49","340.56","17","112.51","737.5","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","31","112.51","737.5","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","128.26","256.52","18","112.51","737.5","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","737.5","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","524.22","35.54","","653.33","499.46","1702.90","11","112.51","737.5","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1052.31","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","486.19","473.60","486.19","1 through 10","201.74","1052.31","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","200.53","424.11","48","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","811.77","417.13","1254.30","13","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","888.27","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","15","201.74","888.27","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","229.99","459.97","1 through 10","201.74","888.27","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","464.00","464.00","464.00","1 through 10","201.74","888.27","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","288.23","35.54","","274.81","274.81","274.81","1 through 10","201.74","888.27","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","11","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","307.41","16","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","99.18","104.56","19","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","146.85","146.85","188.57","1 through 10","94.54","297.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","188.57","","Case rate ($188.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","188.57","157.80","188.57","106","94.54","297.67","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","188.57","","Case rate ($188.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","188.57","157.80","188.57","215","94.54","297.67","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.54","35.54","","90.21","90.21","90.21","1 through 10","94.54","297.67","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.54","35.54","","90.21","90.21","118.00","45","94.54","297.67","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.54","35.54","","118.00","118.00","118.00","1 through 10","94.54","297.67","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1421.31","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","86","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","264.34","264.34","264.34","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","310.99","310.99","310.99","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","326.54","326.54","326.54","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","342.71","342.71","342.71","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1421.31","other","Tricare OPPS"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","13","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","126.29","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","16","112.51","973.5","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","37","112.51","973.5","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","1893.00","1 through 10","112.51","973.5","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","973.5","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.96","35.54","","5679.00","659.33","5679.00","1 through 10","112.51","973.5","percent of total billed charges",""
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","1911.00","1433.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1395.03","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","1911.00","1433.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.77","124.27","1 through 10","112.51","1395.03","other","OPPS APC"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","1810.00","1357.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1321.3","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","1810.00","1357.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.77","124.27","1 through 10","112.51","1321.3","other","OPPS APC"
"CT Max/Facial W&W/O Contrast","PX-35000023","CDM","70488","CPT","0351","RC","","","","both","","","3058.00","2293.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2232.34","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","1 through 10","200.84","1807.48","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","749.78","749.78","749.78","1 through 10","200.84","1807.48","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1238","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1238","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","879.97","35.54","","1097.08","1097.08","1097.08","1 through 10","201.74","1238","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1481.17","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","66","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","281.84","281.84","281.84","1 through 10","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","331.57","331.57","331.57","1 through 10","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","348.15","348.15","348.15","1 through 10","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","365.38","365.38","365.38","19","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MOLINA [1014]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1481.17","other","Tricare OPPS"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","126.29","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","721.11","35.54","","687.20","687.20","687.20","1 through 10","112.51","1481.17","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","262.41","124.27","508.46","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1118.69","1118.69","1118.69","1 through 10","112.51","1014.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","29","112.51","1014.5","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","103","112.51","1014.5","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","22","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","14","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","721.11","35.54","","687.20","687.20","898.90","22","112.51","1014.5","percent of total billed charges",""
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","2094.00","1570.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","200.84","1528.62","other","Multiple Radiology"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","2094.00","1570.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","487.85","487.85","487.85","1 through 10","200.84","1528.62","other","Multiple Radiology"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","2094.00","1570.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","1 through 10","200.84","1528.62","other","OPPS APC"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","2094.00","1570.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","511.00","1 through 10","201.74","1096.57","other","Multiple Imaging"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","2094.00","1570.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1096.57","other","Multiple Radiology"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","2094.00","1570.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","1096.57","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","508.46","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","253.19","506.37","1 through 10","200.84","1500.88","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","118","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","451.20","372.39","770.22","1 through 10","200.84","1500.88","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","473.76","473.76","473.76","1 through 10","200.84","1500.88","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","497.21","482.81","994.42","12","200.84","1500.88","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","209.98","509.20","13","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.80","207.18","511.40","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","255.50","610.66","17","201.74","1028","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","255.50","610.66","42","201.74","1028","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","229.99","459.97","15","201.74","1028","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","574.96","1 through 10","201.74","1028","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","730.70","35.54","","910.74","696.25","910.74","13","201.74","1028","percent of total billed charges",""
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","266.67","11","112.51","1439.56","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","1439.56","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","261.34","261.34","261.34","1 through 10","112.51","1439.56","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","284.98","284.98","1 through 10","112.51","986","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","1 through 10","112.51","986","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","986","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","2741.00","2055.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2000.93","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","2741.00","2055.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","211.41","211.41","1 through 10","200.84","2000.93","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","2741.00","2055.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1370.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","2741.00","2055.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1370.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","2741.00","2055.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2000.93","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","2741.00","2055.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","211.41","211.41","1 through 10","200.84","2000.93","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","2741.00","2055.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1370.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","2741.00","2055.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1370.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","2903.00","2177.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2119.19","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","2903.00","2177.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","211.41","211.41","1 through 10","200.84","2119.19","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","2903.00","2177.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1451.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","2903.00","2177.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1451.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","24","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","316.59","316.59","316.59","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","391.08","391.08","391.08","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","410.44","410.44","410.44","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","170.28","142.49","340.56","12","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","23","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","141.20","268.90","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","591.74","35.54","","597.33","597.33","597.33","1 through 10","112.51","832.5","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","24","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","316.59","316.59","316.59","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","391.08","391.08","391.08","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","410.44","410.44","410.44","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","170.28","142.49","340.56","12","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","23","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","141.20","268.90","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","591.74","35.54","","597.33","597.33","597.33","1 through 10","112.51","832.5","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1287.72","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1287.72","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","24","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","316.59","316.59","316.59","1 through 10","112.51","1287.72","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","391.08","391.08","391.08","1 through 10","112.51","1287.72","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","410.44","410.44","410.44","1 through 10","112.51","1287.72","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","170.28","142.49","340.56","12","112.51","882","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","23","112.51","882","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","882","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","141.20","268.90","1 through 10","112.51","882","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","626.93","35.54","","597.33","597.33","597.33","1 through 10","112.51","882","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","486.19","486.19","486.19","1 through 10","200.84","1605.27","other","Multiple Radiology"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","4658.92","4658.92","4658.92","1 through 10","200.84","1605.27","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","722.80","722.80","722.80","1 through 10","200.84","1605.27","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","200.45","209.98","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.52","35.54","","744.67","744.67","744.67","1 through 10","200.84","1605.27","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","209.19","210.19","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1099.5","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1099.5","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","1379.91","1 through 10","201.74","1099.5","other","Multiple Radiology"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","781.52","35.54","","744.67","744.67","744.67","1 through 10","201.74","1099.5","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","11","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","124.17","124.17","1 through 10","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","340.56","340.56","1 through 10","112.51","913.5","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","1 through 10","112.51","913.5","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","913.5","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","913.5","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","649.32","35.54","","618.93","618.93","618.93","1 through 10","112.51","913.5","percent of total billed charges",""
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1435.91","other","Multiple Radiology"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","266.67","1 through 10","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","284.98","284.98","1 through 10","112.51","983.5","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","284.98","284.98","1 through 10","112.51","983.5","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","1913.00","1913.00","1913.00","1 through 10","112.51","983.5","other","Multiple Radiology"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2300.00","1725.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","1679","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","1922.00","1441.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1403.06","other","Multiple Radiology"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","1922.00","1441.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1403.06","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","1922.00","1441.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","961","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","1922.00","1441.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","683.08","35.54","","258.77","258.77","304.51","1 through 10","112.51","961","percent of total billed charges",""
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1326.41","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1326.41","other","OPPS APC"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","908.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","645.76","35.54","","258.77","258.77","304.51","1 through 10","112.51","908.5","percent of total billed charges",""
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1326.41","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1326.41","other","OPPS APC"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","908.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","645.76","35.54","","258.77","258.77","304.51","1 through 10","112.51","908.5","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","506.37","506.37","1 through 10","200.84","2826.56","other","Multiple Radiology"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","14","200.84","2826.56","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","207.18","209.98","1 through 10","200.84","2826.56","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","200.32","210.19","1 through 10","200.84","2826.56","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","357.59","","Case rate ($357.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2233.02","2233.02","2233.02","1 through 10","201.74","1936","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","357.59","","Case rate ($357.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","357.59","357.59","357.59","1 through 10","201.74","1936","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1376.11","35.54","","1715.33","1715.33","1715.33","1 through 10","201.74","1936","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.53","200.53","211.41","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","831.23","807.17","831.23","1 through 10","200.84","2562.3","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","915.99","915.99","915.99","1 through 10","200.84","2562.3","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1935.17","1935.17","1935.17","1 through 10","201.74","1755","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1755","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1755","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1755","other","Multiple Radiology"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1755","other","Multiple Radiology"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1247.45","35.54","","1188.75","1188.75","1188.75","1 through 10","201.74","1755","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","197.32","208.03","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","FALLON HEALTH [1008]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.53","200.53","200.53","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","200.84","1957.13","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","486.19","477.69","506.37","1 through 10","200.84","1957.13","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","HUMANA [1012]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","494.90","208.87","494.90","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","601.59","129","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","207.18","209.98","23","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","211.41","211.41","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","207.19","211.29","21","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","255.50","610.66","14","201.74","1340.5","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","39","201.74","1340.5","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","441.81","459.97","14","201.74","1340.5","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","482.16","1 through 10","201.74","1340.5","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","952.83","35.54","","1187.75","908.02","2375.50","19","201.74","1340.5","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","379.27","379.27","379.27","1 through 10","200.84","3555.83","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","481.75","879.10","1 through 10","200.84","3555.83","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","67","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","730.69","709.54","730.69","1 through 10","200.84","3555.83","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","723.24","723.24","723.24","1 through 10","200.84","3555.83","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","805.21","805.21","2415.63","16","200.84","3555.83","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","509.20","208.03","511.40","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","516.73","516.73","516.73","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","480.03","516.73","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2685.31","2685.31","2685.31","1 through 10","201.74","2435.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","511.00","11","201.74","2435.5","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","30","201.74","2435.5","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","2435.5","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","253.19","482.16","1 through 10","201.74","2435.5","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1731.15","35.54","","3641.04","1649.55","3641.04","1 through 10","201.74","2435.5","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","481.98","508.46","1 through 10","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","758.54","758.54","758.54","1 through 10","200.84","3572.62","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","883.37","253.19","883.37","1 through 10","200.84","3572.62","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","401.06","13","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","729.48","709.62","729.48","1 through 10","200.84","3572.62","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","722.04","722.04","722.04","1 through 10","200.84","3572.62","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","803.87","803.87","2411.61","13","200.84","3572.62","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2698.35","2698.35","2698.35","1 through 10","201.74","2447","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","2447","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","610.66","20","201.74","2447","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","689.97","229.99","689.97","1 through 10","201.74","2447","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","506.37","464.00","723.24","1 through 10","201.74","2447","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1739.33","35.54","","3658.72","2168.20","3658.73","1 through 10","201.74","2447","percent of total billed charges",""
"Cta Pelvis W&W/O Contrast","PX-35000043","CDM","72191","CPT","0352","RC","","","","both","","","3290.00","2467.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","506.37","506.37","1 through 10","200.84","2401.7","other","Multiple Radiology"
"Cta Pelvis W&W/O Contrast","PX-35000043","CDM","72191","CPT","0352","RC","","","","outpatient","","","3290.00","2467.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","511.00","1 through 10","201.74","1645","other","Multiple Imaging"
"Cta Pelvis W&W/O Contrast","PX-35000043","CDM","72191","CPT","0352","RC","","","","outpatient","","","3290.00","2467.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1645","other","Multiple Imaging"
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.46","165","7.92","57.95","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","50.15","50.15","50.15","1 through 10","7.92","57.95","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","TRICARE [160005]","HB NWH TRICARE","57.95","95","","9.25","9.25","9.25","1 through 10","7.92","57.95","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","57.95","95","","32.10","32.10","32.10","1 through 10","7.92","57.95","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","45.36","26.88","45.36","1 through 10","7.92","57.95","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","34.58","158","5.4","47.85","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","45.36","45.36","1 through 10","5.4","47.85","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","172","5.4","47.85","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","1 through 10","10.58","100.7","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","1 through 10","11.14","83.16","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","79.19","79.19","1 through 10","11.14","83.16","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","95.00","71.25","AETNA [1001]","HB CH AETNA HMO / PPO","55.39","58.3","","52.16","52.16","52.17","12","9.28","90.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","95.00","71.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.34","59.3","","161.73","52.63","161.73","12","9.76","74.53","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","70.73","101.63","14","9.76","74.53","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","1 through 10","7.92","56.05","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","AETNA [1001]","HB CH AETNA HMO / PPO","58.30","58.3","","55.00","55.00","55.00","347","8.45","95","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","73.00","73","","53.02","53.02","53.02","1 through 10","8.45","95","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","TRICARE [160005]","HB NWH TRICARE","95.00","95","","10.39","9.87","10.46","1 through 10","8.45","95","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.45","44.45","","74.57","44.19","74.58","22","8.45","95","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.45","44.45","","44.19","44.19","44.19","1 through 10","8.45","95","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","100.00","75.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.30","59.3","","56.84","56.84","56.84","293","8.88","78.45","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","78.45","78.45","","74.57","74.57","74.57","1 through 10","8.88","78.45","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","78.45","78.45","","74.57","44.19","74.58","295","8.88","78.45","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0300","RC","","","","inpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.42","70.6","","46.02","46.02","46.02","1 through 10","58.24","73.42","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","21","10.11","98.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","89.23","59.19","303.00","32","10.65","81.59","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","74.31","155.30","1 through 10","10.65","81.59","percent of total billed charges",""
"Culture Fungus Blood","PX-30001158","CDM","87103","CPT","0306","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","101.48","101.48","1 through 10","9.29","106.69","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","both","","","122.00","91.50","AETNA [1001]","HB CH AETNA HMO / PPO","71.13","58.3","","67.47","67.47","67.47","1 through 10","10.11","115.9","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","136.14","69.73","136.14","1 through 10","10.65","95.71","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","36.93","36.93","36.93","1 through 10","10.65","95.71","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","8.24","91.2","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","13","8.67","75.31","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","1 through 10","8.67","75.31","percent of total billed charges",""
"Culture Fungus Skin/Hair/Nail","PX-30001156","CDM","87101","CPT","0306","RC","","","","both","","","93.00","69.75","AETNA [1001]","HB CH AETNA HMO / PPO","54.22","58.3","","51.03","51.03","51.03","12","7.56","88.35","percent of total billed charges",""
"Culture Fungus Skin/Hair/Nail","PX-30001156","CDM","87101","CPT","0306","RC","","","","both","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.34","44.45","","69.19","69.19","69.19","1 through 10","7.56","88.35","percent of total billed charges",""
"Culture Fungus Skin/Hair/Nail","PX-30001156","CDM","87101","CPT","0306","RC","","","","outpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","102.96","11","7.95","72.96","percent of total billed charges",""
"Culture Fungus Skin/Hair/Nail","PX-30001156","CDM","87101","CPT","0306","RC","","","","outpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","41.00","69.19","1 through 10","7.95","72.96","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","160","6.5","71.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","75.00","56.25","CHAMPVA [160001]","HB NWH TRICARE","71.25","95","","7.99","7.99","7.99","1 through 10","6.5","71.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","41.39","41.39","41.39","1 through 10","6.5","71.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","75.00","56.25","TRICARE [160005]","HB NWH TRICARE","71.25","95","","7.99","7.99","7.99","1 through 10","6.5","71.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","56.12","56.12","56.12","1 through 10","6.5","71.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","42.78","126","6.84","58.84","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","33.26","56.12","116","6.84","58.84","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","76.00","57.00","AETNA [1001]","HB CH AETNA HMO / PPO","44.31","58.3","","41.96","41.96","83.92","32","9.25","72.2","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","76.00","57.00","TRICARE [160005]","HB NWH TRICARE","72.20","95","","11.38","11.38","11.38","1 through 10","9.25","72.2","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.78","44.45","","54.60","33.71","54.60","1 through 10","9.25","72.2","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","76.00","57.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.07","59.3","","43.36","43.36","43.36","36","9.74","59.62","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","59.62","78.45","","56.89","56.89","56.89","1 through 10","9.74","59.62","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","59.62","78.45","","56.89","33.71","56.89","24","9.74","59.62","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","114.54","32","9.25","98.8","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","104.00","78.00","TRICARE [160005]","HB NWH TRICARE","98.80","95","","11.38","11.38","11.38","1 through 10","9.25","98.8","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.23","44.45","","74.31","46.02","74.31","1 through 10","9.25","98.8","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","59.19","59.19","59.19","36","9.74","81.59","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","104.00","78.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","77.65","77.65","1 through 10","9.74","81.59","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","46.02","77.65","24","9.74","81.59","percent of total billed charges",""
"Culture Typing ID Bld Pthgn&Resist Typing 6+Trgt","PX-30003774","CDM","87154","CPT","0306","RC","","","","both","","","1825.00","1368.75","AETNA [1001]","HB CH AETNA HMO / PPO","1063.98","58.3","","1123.58","1123.58","1123.58","1 through 10","213.7","1735.58","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0300","RC","","","","inpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","67.07","70.6","","41.92","41.92","41.92","1 through 10","53.2","67.07","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","AETNA [1001]","HB CH AETNA HMO / PPO","55.39","58.3","","52.16","52.16","52.16","407","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","69.35","73","","67.16","67.16","67.16","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","50.35","53","","48.76","48.76","48.76","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","69.35","73","","78.20","52.16","78.20","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","TRICARE [160005]","HB NWH TRICARE","90.25","95","","9.72","9.23","9.72","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","90.25","95","","28.88","28.88","28.88","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.23","44.45","","70.73","41.92","70.73","14","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.23","44.45","","41.92","41.92","41.92","1 through 10","7.91","90.25","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.34","59.3","","53.91","53.91","53.91","388","8.33","74.53","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","56.34","59.3","","53.91","53.91","53.91","1 through 10","8.33","74.53","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","67.49","92.00","1 through 10","8.33","74.53","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","41.92","70.73","361","8.33","74.53","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","both","","","4614.00","3460.50","AETNA [1001]","HB CH AETNA HMO / PPO","2689.96","58.3","","3384.99","3384.99","3384.99","1 through 10","2125.14","3888.77","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4614.00","3460.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3899.16","3899.16","1 through 10","1979.41","4472.66","other","ASC "
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4614.00","3460.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","1979.41","4472.66","other","ASC "
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4614.00","3460.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2736.10","59.3","","7728.75","7728.75","7728.75","1 through 10","1979.41","4472.66","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4614.00","3460.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9605.64","4994.08","9605.64","1 through 10","1979.41","4472.66","other","Multiple Surgery"
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","114147.58","","MASSHEALTH [3001]","HB NWH MEDICAID","21308.55","","Case rate ($22,956.60). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $65,386.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23015.64","23015.64","23015.64","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","114147.58","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","55274.43","","Fee schedule rate ($55,274.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","55274.43","55274.43","55274.43","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52131.67","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($34,735.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","34735.90","34735.90","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52131.67","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","38209.14","","Fee schedule rate ($38,209.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38209.16","38209.16","38209.16","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52131.67","","MASSHEALTH [3001]","HB NWH MEDICAID","7046.11","","Case rate ($7,591.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,021.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,698.23 and the sum of the standard inlier and any outlier amount.","12287.01","12287.01","12287.01","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52131.67","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","14061.82","","Fee schedule rate ($14,061.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14061.82","14061.82","14061.82","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","30978.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20045.44","","Standard inlier is a Case rate ($20,045.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,845.37) for the length of stay and the standard reimbursement.","20045.44","20045.44","20045.44","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","30978.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($15,913.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","15913.06","15913.06","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","30978.01","","MASSHEALTH [3001]","HB NWH MEDICAID","5115.51","","Case rate ($5,511.16). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,941.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,232.92 and the sum of the standard inlier and any outlier amount.","5525.33","5525.33","5525.33","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","30978.01","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","7254.29","","Fee schedule rate ($7,254.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7254.24","7254.24","7254.24","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23083.32","","Standard inlier is a Case rate ($23,083.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,276.77) for the length of stay and the standard reimbursement.","22034.38","22034.38","23083.32","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24796.09","","Standard inlier is a Case rate ($24,796.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,519.70) for the length of stay and the standard reimbursement.","23668.99","23668.99","23668.99","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($21,425.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","21425.84","21425.84","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","MASSHEALTH [3001]","HB NWH MEDICAID","7046.11","","Case rate ($7,591.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,021.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7610.59","7610.59","7901.73","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","10987.53","","Fee schedule rate ($10,987.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10987.53","10987.53","10987.53","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","31803.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22305.13","","Fee schedule rate ($22,305.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22305.13","22305.13","22305.13","1 through 10","5115.51","121095.57","case rate",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","34","12.69","100.7","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","106.00","79.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","77.38","73","","75.19","75.19","75.19","1 through 10","12.69","100.7","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.12","44.45","","79.19","79.19","79.19","1 through 10","12.69","100.7","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","48","13.35","83.16","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","46.93","79.19","37","13.35","83.16","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","16","18.15","98.34","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","96.00","72.00","TRICARE [160005]","HB NWH TRICARE","91.20","95","","21.20","21.20","21.20","1 through 10","18.15","98.34","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","163.50","46","11.72","75.31","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","39","11.72","75.31","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3564.11","50.1","","2817.13","2817.13","2817.13","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5580.93","78.45","","8268.00","8268.00","8268.00","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","7114.00","5335.50","WELLPOINT [1015]","HB CH WELLPOINT","5542.52","77.91","","14779.88","14779.88","14779.88","1 through 10","3051.91","5542.52","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3490.84","49.07","","4732.70","4732.70","4732.70","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3564.11","50.1","","4839.81","4739.39","4839.81","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5580.93","78.45","","8328.41","4935.51","8328.41","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4051.00","3038.25","AETNA [1001]","HB CH AETNA HMO / PPO","2361.73","58.3","","3470.61","3470.61","3470.61","1 through 10","1565.78","3156.13","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2872.84","2872.84","1 through 10","1565.78","4472.66","other","ASC "
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2876.82","2876.82","2876.82","1 through 10","1565.78","4472.66","other","ASC "
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2402.24","59.3","","3498.42","3498.42","3498.42","1 through 10","1565.78","4472.66","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3679.58","3679.58","3679.58","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cysto W/Catheterizat Ureteral","PX-76001277","CDM","52005","CPT","0761","RC","","","","outpatient","","","6749.00","5061.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5294.59","78.45","","13659.00","13659.00","13659.00","1 through 10","2699.6","5294.59","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1987.83","49.07","","2813.15","2813.15","2813.15","1 through 10","1620.4","3178.01","percent of total billed charges",""
"Cysto W/Indwelling Stent Ureteral","PX-76001286","CDM","52332","CPT","0761","RC","","","","both","","","6749.00","5061.75","AETNA [1001]","HB CH AETNA HMO / PPO","3934.67","58.3","","3739.08","3384.99","3739.08","1 through 10","3576.97","5258.15","percent of total billed charges",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt","PX-76002686","CDM","52356","CPT","0761","RC","","","","both","","","2104.00","1578.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1115.12","53","","4605.17","4605.17","4605.17","1 through 10","902.62","1639.23","percent of total billed charges",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt","PX-76002686","CDM","52356","CPT","0761","RC","","","","outpatient","","","2104.00","1578.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1650.59","78.45","","10139.70","10139.70","10139.70","1 through 10","841.6","1650.59","percent of total billed charges",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE","PX-76002686","CDM","52356","CPT","0761","RC","","","50","both","","","2104.00","1578.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($4,378.50). Procedure 2, Per diem ($2,189.25). Procedures 3 - 9999, Per diem ($1,094.63).","3721.73","3721.73","3721.73","1 through 10","","","per diem",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE","PX-76002686","CDM","52356","CPT","0761","RC","","","50","both","","","2104.00","1578.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($4,378.50). Procedure 2, Per diem ($2,189.25). Procedures 3 - 9999, Per diem ($1,094.63).","4378.50","4378.50","4378.50","1 through 10","","","per diem",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE","PX-76002686","CDM","52356","CPT","0761","RC","","","50","both","","","2104.00","1578.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($4,827). Procedure 2, Per diem ($2,413.50). Procedures 3 - 9999, Per diem ($1,206.75).","4827.00","4827.00","4827.00","1 through 10","","","per diem",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","AETNA [1001]","HB CH AETNA HMO / PPO","1056.98","58.3","","2343.98","2343.98","2343.98","1 through 10","562.25","1412.51","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1456.23","1456.23","1456.23","1 through 10","562.25","1412.51","other","Multiple Surgery"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","MEDICARE [2001]","HB NWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","792.66","792.66","792.66","1 through 10","562.25","1412.51","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","562.25","1412.51","per diem",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","WELLPOINT [1015]","HB CH WELLPOINT","1412.51","77.91","","6676.49","6676.49","6676.49","1 through 10","562.25","1412.51","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","AETNA [1001]","HB CH AETNA HMO / PPO","2361.73","58.3","","3384.99","3384.99","3384.99","1 through 10","1565.78","3156.13","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","4134.00","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2027.69","2027.69","2027.69","1 through 10","1565.78","3156.13","other","Multiple Surgery"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MEDICARE [2001]","HB NWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2223.03","2432.73","31","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1652.00","1652.00","1652.00","1 through 10","1565.78","3156.13","per diem",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1822.00","1822.00","1822.00","1 through 10","1565.78","3156.13","per diem",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.48","2183.97","2391.48","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4782.16","2384.08","4782.16","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2813.15","2872.84","1 through 10","1565.78","4472.66","other","ASC "
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2876.82","2817.13","2876.82","1 through 10","1565.78","4472.66","other","ASC "
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3679.58","3679.58","3679.58","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3867.48","3538.66","3867.48","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","218.00","163.50","TRICARE [160005]","HB NWH TRICARE","207.10","95","","31.92","30.32","31.92","13","25.96","207.1","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","218.00","163.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","124.23","212.00","752","72.72","177.12","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","218.00","163.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","122.91","124.23","1 through 10","72.72","177.12","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.90","44.45","","162.98","96.59","162.99","19","72.72","177.12","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.02","78.45","","162.99","96.59","162.99","576","72.72","177.12","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.90","44.45","","96.59","96.59","96.59","1 through 10","72.72","177.12","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","95.70","58","","112.36","112.36","112.36","1 through 10","35.96","179.9","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","103.13","62.5","","123.82","120.23","371.46","1 through 10","35.96","179.9","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","93.76","93.76","93.76","1 through 10","82.5","129.44","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","123.01","72.90","123.01","1 through 10","82.5","129.44","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","18","14.1","114.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","118.00","118.00","118.00","1 through 10","14.1","114.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","90.72","53.76","90.72","1 through 10","14.1","114.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","12","14.84","94.92","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","181.44","90.72","181.44","1 through 10","14.84","94.92","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","122.00","91.50","AETNA [1001]","HB CH AETNA HMO / PPO","71.13","58.3","","67.47","67.47","67.47","19","16.51","115.9","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","122.00","91.50","TRICARE [160005]","HB NWH TRICARE","115.90","95","","119.00","20.30","119.00","1 through 10","16.51","115.9","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.23","44.45","","91.49","91.49","91.49","1 through 10","16.51","115.9","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","69.73","69.73","209.19","13","14.72","95.71","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","91.49","91.49","91.49","1 through 10","14.72","95.71","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","22","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","MEDICARE [2001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","63.45","126.90","173","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","62.18","62.18","22","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","62.19","62.39","11","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","WELLPOINT [1015]","HB CH WELLPOINT","281.26","77.91","","276.45","276.45","627.45","1 through 10","60.28","281.26","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","361.00","270.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.07","59.3","","205.69","205.69","205.69","11","90.37","283.2","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","269.85","159.92","269.85","1 through 10","90.37","283.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","120.20","120.20","171.80","781","25.96","296.4","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","154.76","154.76","154.76","1 through 10","25.96","296.4","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","160.59","160.59","160.59","1 through 10","25.96","296.4","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","120.20","34.16","180.20","1 through 10","25.96","296.4","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","312.00","234.00","TRICARE [160005]","HB NWH TRICARE","296.40","95","","32.07","32.07","32.07","1 through 10","25.96","296.4","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","177.56","177.56","532.68","86","80.8","244.76","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","138.05","138.05","138.05","1 through 10","80.8","244.76","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","232.95","138.05","232.95","70","80.8","244.76","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","138.05","138.05","138.05","1 through 10","80.8","244.76","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","123.01","123.01","123.01","1 through 10","61.27","129.44","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","90.72","90.72","90.72","27","19.85","156.75","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","93.76","93.76","402.00","35","52.9","135.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","123.01","72.90","123.01","35","52.9","135.51","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","36.29","32.64","217.73","1 through 10","29.34","51.42","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","38.28","58","","30.28","30.28","30.28","1 through 10","29.34","51.42","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","41.25","62.5","","33.37","32.40","33.37","17","29.34","51.42","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.34","44.45","","29.16","29.16","29.16","1 through 10","29.34","51.42","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB CH WELLPOINT","51.42","77.91","","50.41","50.41","50.41","1 through 10","29.34","51.42","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","37.51","37.50","37.51","13","33","51.78","percent of total billed charges",""
"Cytopath Fna Eval Each Addl","PX-31000096","CDM","88177","CPT","0311","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","49.20","29.16","49.21","29","33","51.78","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","AETNA [1001]","HB CH AETNA HMO / PPO","161.49","58.3","","305.05","137.19","305.05","1 through 10","123.13","768.52","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","100.12","200.24","11","123.13","768.52","other","OPPS APC"
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","202.21","73","","196.37","196.37","196.37","1 through 10","123.13","768.52","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","203.50","82","123.13","768.52","other","OPPS APC"
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","398.86","182.69","398.86","20","123.13","768.52","other","OPPS APC"
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.13","44.45","","122.56","122.56","122.56","1 through 10","123.13","768.52","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","91.35","199.63","14","123.13","768.52","other","OPPS APC"
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","277.00","207.75","WELLPOINT [1015]","HB CH WELLPOINT","215.81","77.91","","211.86","211.86","480.86","1 through 10","123.13","768.52","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","outpatient","","","277.00","207.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","164.26","59.3","","157.63","157.63","157.64","15","125.76","489.19","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","outpatient","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","217.31","78.45","","206.81","122.56","206.81","22","125.76","489.19","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4875.00","3656.25","AETNA [1001]","HB CH AETNA HMO / PPO","2842.13","58.3","","4949.91","4949.91","4949.91","1 through 10","2091.38","3888.77","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4875.00","3656.25","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","2091.38","3888.77","other","OPPS APC"
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4875.00","3656.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3823.55","1911.78","3823.55","1 through 10","1873.9","3824.44","other","ASC "
"D&C, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses,MAJOR","544","DRG","","","","","","","","inpatient","","","24650.52","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9111.94","","Fee schedule rate ($9,111.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9111.94","9111.94","9111.94","1 through 10","5211.94","37857.68","case rate",""
"D&C, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses,MODERATE","544","DRG","","","","","","","","inpatient","","","45311.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6131.65","","Fee schedule rate ($6,131.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6131.65","6131.65","6131.65","1 through 10","5211.94","37857.68","case rate",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","MS-DRG","","","","","","","","inpatient","","","33050.27","24787.70","MEDICARE [2001]","HB NWH MEDICARE","19520.15","","Case rate ($19,520.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,237.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,379.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,298.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,163.46. The transfer operating threshold is the transfer adjustment factor * $18,237.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,356.69. The transfer capital threshold is the transfer adjustment factor * $1,356.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18649.31","18649.31","18649.31","1 through 10","17398.19","19520.15","other","Inpatient DRG"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/McC","745","MS-DRG","","","","","","","","inpatient","","","31360.72","23520.54","MEDICARE [2001]","HB NWH MEDICARE","10836.05","","Case rate ($10,836.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,123.98, add-ons for qualifying new technology services are included. If operating cost exceeds $55,266.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,695.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,082.93. The transfer operating threshold is the transfer adjustment factor * $10,123.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $753.13. The transfer capital threshold is the transfer adjustment factor * $753.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9780.86","9780.86","9780.86","1 through 10","9658.11","10836.05","other","Inpatient DRG"
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","AETNA [1001]","HB CH AETNA HMO / PPO","211.63","58.3","","464.71","67.87","1012.10","221","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","211.63","58.3","","293.04","293.04","293.04","11","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","192.39","53","","983.89","983.89","983.89","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","210.54","58","","677.18","677.18","677.18","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","226.88","62.5","","46.58","46.58","46.58","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","264.99","73","","747.15","747.15","747.15","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.35","44.45","","1141.67","481.21","1141.67","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.35","44.45","","76.54","76.54","76.54","1 through 10","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.00","272.25","WELLPOINT [1015]","HB CH WELLPOINT","282.81","77.91","","273.64","94.28","1367.51","138","161.35","282.81","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.00","272.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","215.26","59.3","","720.78","230.14","2010.94","427","181.5","284.77","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.00","272.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","215.26","59.3","","344.45","344.45","344.45","1 through 10","181.5","284.77","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.00","272.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","284.77","78.45","","1120.13","1120.13","1120.13","1 through 10","181.5","284.77","percent of total billed charges",""
"DART CHONDRAL 1.3X18MM PLLA DOUBLE REVERSED BARBED BX/5EA","SUP-ITM-10318163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.00","272.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","284.77","78.45","","456.17","105.33","1284.66","242","181.5","284.77","percent of total billed charges",""
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2156.00","1617.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","1142.68","1981.66","per diem",""
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2156.00","1617.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.15","1887.15","1887.15","1 through 10","1142.68","1981.66","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1113.66","1113.66","1113.66","1 through 10","924.92","4472.66","other","ASC "
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","922.00","691.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","813.47","813.47","813.47","1 through 10","314.08","718.33","other","Multiple Surgery"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","922.00","691.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","254.29","508.58","1 through 10","314.08","723.31","other","ASC "
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","922.00","691.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","738.09","738.09","738.09","1 through 10","314.08","723.31","other","Multiple Surgery"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1145.00","858.75","MEDICARE [2001]","HB NWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","482.89","892.07","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1145.00","858.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","713.40","713.40","713.40","1 through 10","482.89","892.07","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","399.25","390.97","399.25","1 through 10","482.89","898.25","other","ASC "
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","567.40","567.40","1134.79","1 through 10","482.89","898.25","other","Multiple Surgery"
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","both","","","2156.00","1617.00","AETNA [1001]","HB CH AETNA HMO / PPO","1256.95","58.3","","1692.50","1692.50","1692.50","1 through 10","924.92","1679.74","percent of total billed charges",""
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1057.95","49.07","","1963.63","1963.63","1963.63","1 through 10","862.4","1691.38","percent of total billed charges",""
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1080.16","50.1","","3932.70","3932.70","3932.70","1 through 10","862.4","1691.38","percent of total billed charges",""
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1278.51","59.3","","3769.15","3769.15","3769.15","1 through 10","862.4","1691.38","percent of total billed charges",""
"Debride/Remove FB Skin/Subq/Muscle","PX-76000020","CDM","11011","CPT","0761","RC","","","","outpatient","","","1433.00","1074.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","717.93","50.1","","479.00","479.00","479.00","1 through 10","573.2","1124.19","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","AETNA [1001]","HB CH AETNA HMO / PPO","74.62","58.3","","70.31","70.31","70.31","1 through 10","56.9","99.72","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","74.24","58","","26.51","26.51","26.51","1 through 10","56.9","99.72","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","93.44","73","","70.30","70.30","70.30","1 through 10","56.9","99.72","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.90","44.45","","56.49","56.49","56.49","1 through 10","56.9","99.72","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","WELLPOINT [1015]","HB CH WELLPOINT","99.72","77.91","","221.66","97.66","221.66","1 through 10","56.9","99.72","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","128.00","96.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","75.90","59.3","","72.66","72.61","72.66","1 through 10","64","100.42","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","128.00","96.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","100.42","78.45","","95.33","95.33","124.00","1 through 10","64","100.42","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","609.00","456.75","MEDICARE [2001]","HB NWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1181.70","393.90","1181.70","1 through 10","270.7","474.47","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","609.00","456.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","329.78","","Case rate ($329.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","476.86","476.86","476.86","1 through 10","288.38","884.1","other","ASC "
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","288.38","","Case rate ($288.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","686.34","686.34","686.34","1 through 10","288.38","884.1","other","Multiple Surgery"
"Degenerative Nervous System Disorders Except Multiple Sclerosis,EXTREME","042","DRG","","","","","","","","inpatient","","","64627.13","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11733.0168","","Fee schedule rate ($38,743.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11733.0168","38743.96","38743.96","1 through 10","1860","63926.95","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,EXTREME","042","DRG","","","","","","","","inpatient","","","64627.13","","MASSHEALTH [3001]","HB NWH MEDICAID","30773.06","","Case rate ($33,153.11). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $75,583.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","33238.37","33238.37","33238.37","1 through 10","1860","63926.95","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","59688.64","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11733.0168","","Fee schedule rate ($33,020.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11733.0168","33020.12","33020.12","1 through 10","1860","63926.95","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","19041.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28912.10","","Standard inlier is a Case rate ($28,912.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,259, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,103.95) for the length of stay and the standard reimbursement.","20511.79","20511.79","21488.54","1 through 10","1860","63926.95","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","19041.63","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","20246.15","","Case rate ($21,812.03). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $64,242.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,363.25 and the sum of the standard inlier and any outlier amount.","5554.76","5554.76","5554.76","1 through 10","1860","63926.95","case rate",""
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","40948.13","30711.10","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1358.03","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","18681.57","18681.57","18681.57","1 through 10","1293.36","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","40948.13","30711.10","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","17994.03","17994.03","21594.01","1 through 10","1293.36","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","40948.13","30711.10","MEDICARE [2001]","HB NWH MEDICARE","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","23899.23","11949.77","23942.51","33","1293.36","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","40948.13","30711.10","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","21357.22","21350.45","41091.64","1 through 10","1293.36","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","40948.13","30711.10","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14258.58","14258.58","14258.58","1 through 10","1293.36","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1345.91","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11976.36","11976.36","11976.36","1 through 10","1281.82","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1281.82","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11510.61","11507.14","11510.61","1 through 10","1281.82","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","MEDICARE [2001]","HB NWH MEDICARE","1281.82","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12735.73","6714.87","12758.63","56","1281.82","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1281.82","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11383.77","11383.77","11412.77","1 through 10","1281.82","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","1281.82","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12985.52","12985.52","12985.52","1 through 10","1281.82","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","26637.03","19977.77","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1281.82","","Case rate ($1,281.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8989.24","8989.24","8989.24","1 through 10","1281.82","13299.33","other","Inpatient Psych"
"Del Vaginal Only","PX-72000016","CDM","59409","CPT","0720","RC","","","","both","","","8843.00","6632.25","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6014.15","6014.15","6014.15","1 through 10","2125.14","6889.58","other","Multiple Surgery"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","27942.57","20956.93","MEDICARE [2001]","HB NWH MEDICARE","8666.94","","Case rate ($8,666.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,097.41, add-ons for qualifying new technology services are included. If operating cost exceeds $53,239.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,544.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,064.57. The transfer operating threshold is the transfer adjustment factor * $8,097.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.37. The transfer capital threshold is the transfer adjustment factor * $602.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8993.39","8977.25","8993.39","1 through 10","7724.79","9339.1","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","31089.90","23317.42","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15320.45","","Case rate ($14,874.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,279.87, add-ons for qualifying new technology services are included. If operating cost exceeds $60,422.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,078.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,737.56. The transfer operating threshold is the transfer adjustment factor * $15,279.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.67. The transfer capital threshold is the transfer adjustment factor * $1,136.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14707.67","14707.67","14707.67","1 through 10","14576.74","16354.58","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","31089.90","23317.42","MEDICARE [2001]","HB NWH MEDICARE","16354.58","","Case rate ($16,354.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,279.87, add-ons for qualifying new technology services are included. If operating cost exceeds $60,422.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,078.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,217.91. The transfer operating threshold is the transfer adjustment factor * $15,279.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,136.67. The transfer capital threshold is the transfer adjustment factor * $1,136.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15628.57","978.30","15656.67","11","14576.74","16354.58","other","Inpatient DRG"
"Dental And Oral Diseases Without Cc/McC","159","MS-DRG","","","","","","","","inpatient","","","12724.77","9543.58","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5985.88","5985.88","5985.88","1 through 10","6015.62","7272.75","case rate",""
"Dental And Oral Diseases Without Cc/McC","159","MS-DRG","","","","","","","","inpatient","","","12724.77","9543.58","MEDICARE [2001]","HB NWH MEDICARE","6749.31","","Case rate ($6,749.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,305.79, add-ons for qualifying new technology services are included. If operating cost exceeds $51,448.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,411.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,280.23. The transfer operating threshold is the transfer adjustment factor * $6,305.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.09. The transfer capital threshold is the transfer adjustment factor * $469.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6295.34","6295.34","6295.34","1 through 10","6015.62","7272.75","other","Inpatient DRG"
"Dental Diseases And Disorders,EXTREME","114","DRG","","","","","","","","inpatient","","","18710.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9460.2822","","Fee schedule rate ($65,655.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9460.2822","65655.26","65655.26","1 through 10","4433.52","108330.17","case rate",""
"Dental Diseases And Disorders,MAJOR","114","DRG","","","","","","","","inpatient","","","11135.74","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9460.2822","","Fee schedule rate ($23,956.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9460.2822","23956.54","23956.54","1 through 10","4433.52","108330.17","case rate",""
"Dentoalveolar Unlstd Proc","PX-75000334","CDM","41899","CPT","0761","RC","","","","outpatient","","","1258.00","943.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","745.99","59.3","","2985.00","2985.00","2985.00","1 through 10","567.68","986.9","percent of total billed charges",""
"Dentoalveolar Unlstd Proc","PX-75000334","CDM","41899","CPT","0761","RC","","","","outpatient","","","1258.00","943.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","725.87","57.7","","6371.30","6371.30","6371.30","1 through 10","567.68","986.9","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","12.99","105.45","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","both","","","111.00","83.25","TRICARE [160005]","HB NWH TRICARE","105.45","95","","15.97","15.97","15.97","1 through 10","12.99","105.45","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","1 through 10","13.66","87.08","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.66","87.08","percent of total billed charges",""
"Depressive Disorders,MODERATE","751","DRG","","","","","","","","inpatient","","","33811.55","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","16104.80","","Fee schedule rate ($16,104.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17690.00","17690.00","17690.00","1 through 10","954.59","53705.61","case rate",""
"Depressive Disorders,MODERATE","751","DRG","","","","","","","","inpatient","","","33811.55","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5285.74","","Fee schedule rate ($5,285.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2018.89","2018.89","2018.89","1 through 10","954.59","53705.61","case rate",""
"Depressive Disorders,MODERATE","751","DRG","","","","","","","","inpatient","","","33811.55","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11266.30","","Fee schedule rate ($11,266.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","790.99","790.99","790.99","1 through 10","954.59","53705.61","case rate",""
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","27848.40","20886.30","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1224.08","","Case rate ($1,224.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7353.75","7353.75","7353.75","1 through 10","1224.08","9658.34","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","27848.40","20886.30","MEDICARE [2001]","HB NWH MEDICARE","1224.08","","Case rate ($1,224.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8724.32","8724.32","8724.32","1 through 10","1224.08","9658.34","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","27848.40","20886.30","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","1224.08","","Case rate ($1,224.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8943.65","8943.65","8943.65","1 through 10","1224.08","9658.34","other","Inpatient Psych"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","both","","","5356.00","4017.00","MEDICARE [2001]","HB NWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","2101.12","4172.86","other","OPPS APC"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","both","","","5356.00","4017.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3004.00","3004.00","3004.00","1 through 10","2101.12","4172.86","other","OPPS APC"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","outpatient","","","5356.00","4017.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3775.00","3775.00","3775.00","1 through 10","1873.9","4201.78","other","ASC "
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","outpatient","","","5356.00","4017.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3860.43","3860.43","3860.43","1 through 10","1873.9","4201.78","other","ASC "
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","MEDICARE [2001]","HB NWH MEDICARE","2865.14","","APC Price ($2,865.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","2101.12","3958.61","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","2101.12","3958.61","per diem",""
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3204.64","3204.64","3204.64","1 through 10","2101.12","3958.61","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","outpatient","","","5081.00","3810.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3775.00","3775.00","3775.00","1 through 10","1873.9","3986.04","other","ASC "
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5081.00","3810.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2557.79","2557.79","2557.79","1 through 10","1548.96","3986.04","other","ASC "
"Dest Nerve Cerv/Thor Sgl","PX-76001585","CDM","64633","CPT","0761","RC","","","","both","","","4417.00","3312.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.15","2280.15","2280.15","1 through 10","1468.33","3441.28","other","OPPS APC"
"Dest Nerve Cerv/Thor Sgl|BILATERAL PROCEDURE","PX-76001585","CDM","64633","CPT","0761","RC","","","50","outpatient","","","4417.00","3312.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4041.09","4041.09","4041.09","1 through 10","1894.89","5440.16","other","ASC "
"Dest Nerve Lumbar/Sacral Ea Add","PX-76001588","CDM","64636","CPT","0761","RC","","","","both","","","2169.00","1626.75","AETNA [1001]","HB CH AETNA HMO / PPO","1264.53","58.3","","1195.80","1195.80","1195.80","1 through 10","1149.57","1689.87","percent of total billed charges",""
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","3534.00","2650.50","AETNA [1001]","HB CH AETNA HMO / PPO","2060.32","58.3","","1948.21","1948.21","1948.21","1 through 10","1468.33","2753.34","percent of total billed charges",""
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","3534.00","2650.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.55","2073.06","2280.55","1 through 10","1468.33","2753.34","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl|BILATERAL PROCEDURE","PX-76001587","CDM","64635","CPT","0761","RC","","","50","both","","","3534.00","2650.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","2815.50","2815.50","2815.50","1 through 10","1516.09","8567.71","per diem",""
"Dest Nerve Lumbar/Sacral Sgl|BILATERAL PROCEDURE","PX-76001587","CDM","64635","CPT","0761","RC","","","50","outpatient","","","3534.00","2650.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4041.09","4041.09","4041.09","1 through 10","2798.54","5440.16","other","ASC "
"Dest Nerve Lumbar/Sacral Sgl|BILATERAL PROCEDURE","PX-76001587","CDM","64635","CPT","0761","RC","","","50","outpatient","","","3534.00","2650.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3962.73","3962.73","4046.69","1 through 10","2798.54","5440.16","other","ASC "
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-76002665","CDM","64624","CPT","0761","RC","","","","both","","","2048.00","1536.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.55","2272.65","2280.55","1 through 10","1085.44","5759.82","other","OPPS APC"
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-98301901","CDM","64624","CPT","0983","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.55","2272.65","2280.55","1 through 10","405.45","5759.82","other","OPPS APC"
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB CH AETNA HMO / PPO","306.08","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB CH AETNA HMO / PPO","306.08","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","367.42","367.42","367.42","1 through 10","176.52","528.85","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","both","","","313.00","234.75","AETNA [1001]","HB CH AETNA HMO / PPO","182.48","58.3","","172.37","172.37","172.37","1 through 10","134.28","243.86","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB CH AETNA HMO / PPO","125.35","58.3","","172.37","172.37","172.37","1 through 10","92.24","167.51","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB CH AETNA HMO / PPO","125.35","58.3","","172.37","172.37","172.37","1 through 10","92.24","167.51","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","both","","","313.00","234.75","AETNA [1001]","HB CH AETNA HMO / PPO","182.48","58.3","","172.37","172.37","172.37","1 through 10","134.28","243.86","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","both","","","313.00","234.75","AETNA [1001]","HB CH AETNA HMO / PPO","182.48","58.3","","172.37","172.37","172.37","1 through 10","134.28","243.86","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","both","","","313.00","234.75","AETNA [1001]","HB CH AETNA HMO / PPO","182.48","58.3","","172.37","172.37","172.37","1 through 10","134.28","243.86","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","AETNA [1001]","HB CH AETNA HMO / PPO","234.16","58.3","","464.71","67.87","1012.10","221","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","234.16","58.3","","293.04","293.04","293.04","11","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.87","53","","983.89","983.89","983.89","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","232.95","58","","677.18","677.18","677.18","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","251.03","62.5","","46.58","46.58","46.58","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","293.20","73","","747.15","747.15","747.15","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.53","44.45","","1141.67","481.21","1141.67","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.53","44.45","","76.54","76.54","76.54","1 through 10","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","WELLPOINT [1015]","HB CH WELLPOINT","312.92","77.91","","273.64","94.28","1367.51","138","178.53","312.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","CIGNA [1006]","HB CH CIGNA HMO / PPO","238.17","59.3","","720.78","230.14","2010.94","427","200.82","315.09","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","238.17","59.3","","344.45","344.45","344.45","1 through 10","200.82","315.09","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","315.09","78.45","","1120.13","1120.13","1120.13","1 through 10","200.82","315.09","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","315.09","78.45","","456.17","105.33","1284.66","242","200.82","315.09","percent of total billed charges",""
"DEVICE DILATATION L 4CM OD 15FR UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10027245","CDM","C1726","HCPCS","0272","RC","","","","both","","","1010.91","758.18","WELLPOINT [1015]","HB CH WELLPOINT","787.60","77.91","","582.67","582.67","582.67","1 through 10","449.35","787.6","percent of total billed charges",""
"DEVICE DILATATION L 4CM OD 15FR UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10027245","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1010.91","758.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","793.06","78.45","","394.74","331.66","1115.07","1 through 10","505.46","793.06","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","1530.90","1160.93","1884.08","89","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","5253.92","5253.92","5253.92","1 through 10","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","330.60","58","","12181.47","12181.47","12181.47","1 through 10","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","356.25","62.5","","1350.68","1350.68","1350.68","1 through 10","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","1910.74","891.94","1910.74","1 through 10","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","1829.79","1561.50","2617.12","88","253.37","444.09","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","1359.46","1201.30","1689.00","61","285","447.17","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","338.01","59.3","","1718.92","1718.92","1718.92","1 through 10","285","447.17","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","1910.74","1019.06","2344.84","74","285","447.17","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","464.71","67.87","1012.10","221","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","293.04","293.04","293.04","11","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","983.89","983.89","983.89","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","391.50","58","","677.18","677.18","677.18","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.88","62.5","","46.58","46.58","46.58","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","747.15","747.15","747.15","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","1141.67","481.21","1141.67","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","76.54","76.54","76.54","1 through 10","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","273.64","94.28","1367.51","138","300.04","525.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","720.78","230.14","2010.94","427","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.28","59.3","","344.45","344.45","344.45","1 through 10","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","1120.13","1120.13","1120.13","1 through 10","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","456.17","105.33","1284.66","242","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB CH AETNA HMO / PPO","398.77","58.3","","464.71","67.87","1012.10","221","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","398.77","58.3","","293.04","293.04","293.04","11","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.52","53","","983.89","983.89","983.89","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","396.72","58","","677.18","677.18","677.18","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","427.50","62.5","","46.58","46.58","46.58","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.32","73","","747.15","747.15","747.15","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.04","44.45","","1141.67","481.21","1141.67","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.04","44.45","","76.54","76.54","76.54","1 through 10","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","WELLPOINT [1015]","HB CH WELLPOINT","532.90","77.91","","273.64","94.28","1367.51","138","304.04","532.9","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","405.61","59.3","","720.78","230.14","2010.94","427","342","536.6","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","405.61","59.3","","344.45","344.45","344.45","1 through 10","342","536.6","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","1120.13","1120.13","1120.13","1 through 10","342","536.6","percent of total billed charges",""
"DEVICE FIXATION 20MM ENDOBUTTON CL BTB CORTICAL","SUP-ITM-10049532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","456.17","105.33","1284.66","242","342","536.6","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB CH AETNA HMO / PPO","454.74","58.3","","464.71","67.87","1012.10","221","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.74","58.3","","293.04","293.04","293.04","11","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.40","53","","983.89","983.89","983.89","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","452.40","58","","677.18","677.18","677.18","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","487.50","62.5","","46.58","46.58","46.58","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","569.40","73","","747.15","747.15","747.15","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.71","44.45","","1141.67","481.21","1141.67","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.71","44.45","","76.54","76.54","76.54","1 through 10","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","273.64","94.28","1367.51","138","346.71","607.7","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.54","59.3","","720.78","230.14","2010.94","427","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","462.54","59.3","","344.45","344.45","344.45","1 through 10","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","1120.13","1120.13","1120.13","1 through 10","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","456.17","105.33","1284.66","242","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","AETNA [1001]","HB CH AETNA HMO / PPO","848.27","58.3","","464.71","67.87","1012.10","221","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","848.27","58.3","","293.04","293.04","293.04","11","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.15","53","","983.89","983.89","983.89","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","843.90","58","","677.18","677.18","677.18","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","909.38","62.5","","46.58","46.58","46.58","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","747.15","747.15","747.15","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","1141.67","481.21","1141.67","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","76.54","76.54","76.54","1 through 10","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","WELLPOINT [1015]","HB CH WELLPOINT","1133.59","77.91","","273.64","94.28","1367.51","138","646.75","1133.59","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.82","59.3","","720.78","230.14","2010.94","427","727.5","1141.45","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","862.82","59.3","","344.45","344.45","344.45","1 through 10","727.5","1141.45","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","1120.13","1120.13","1120.13","1 through 10","727.5","1141.45","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","456.17","105.33","1284.66","242","727.5","1141.45","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1337.82","1003.36","AETNA [1001]","HB CH AETNA HMO / PPO","779.95","58.3","","2190.90","412.50","9264.59","16","594.66","1042.3","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1337.82","1003.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","775.94","58","","1903.20","1903.20","3826.66","1 through 10","594.66","1042.3","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1337.82","1003.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","836.14","62.5","","2186.25","2186.25","2186.25","32","594.66","1042.3","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1337.82","1003.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.61","73","","5556.60","5556.60","5556.60","1 through 10","594.66","1042.3","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1337.82","1003.36","WELLPOINT [1015]","HB CH WELLPOINT","1042.30","77.91","","1955.15","885.83","3150.40","26","594.66","1042.3","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1337.82","1003.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.33","59.3","","831.03","253.22","2394.88","18","668.91","1049.52","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1337.82","1003.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.52","78.45","","2481.69","1563.74","8149.28","1 through 10","668.91","1049.52","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","12000.00","9000.00","AETNA [1001]","HB CH AETNA HMO / PPO","6996.00","58.3","","2190.90","412.50","9264.59","16","5334","9349.2","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","12000.00","9000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6960.00","58","","1903.20","1903.20","3826.66","1 through 10","5334","9349.2","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","12000.00","9000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7500.00","62.5","","2186.25","2186.25","2186.25","32","5334","9349.2","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","12000.00","9000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8760.00","73","","5556.60","5556.60","5556.60","1 through 10","5334","9349.2","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","12000.00","9000.00","WELLPOINT [1015]","HB CH WELLPOINT","9349.20","77.91","","1955.15","885.83","3150.40","26","5334","9349.2","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12000.00","9000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7116.00","59.3","","831.03","253.22","2394.88","18","6000","9414","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12000.00","9000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9414.00","78.45","","2481.69","1563.74","8149.28","1 through 10","6000","9414","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","2832.20","2124.15","AETNA [1001]","HB CH AETNA HMO / PPO","1651.17","58.3","","1952.48","1215.31","1952.48","1 through 10","1258.91","2206.57","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","2832.20","2124.15","WELLPOINT [1015]","HB CH WELLPOINT","2206.57","77.91","","2735.63","2146.75","4736.42","1 through 10","1258.91","2206.57","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2832.20","2124.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","1679.49","59.3","","1597.25","1552.67","1756.87","1 through 10","1416.1","2221.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2832.20","2124.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2221.86","78.45","","2647.39","1568.87","3176.87","1 through 10","1416.1","2221.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","3945.36","2959.02","AETNA [1001]","HB CH AETNA HMO / PPO","2300.14","58.3","","1952.48","1215.31","1952.48","1 through 10","1753.71","3073.83","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","3945.36","2959.02","WELLPOINT [1015]","HB CH WELLPOINT","3073.83","77.91","","2735.63","2146.75","4736.42","1 through 10","1753.71","3073.83","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3945.36","2959.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","2339.60","59.3","","1597.25","1552.67","1756.87","1 through 10","1972.68","3095.13","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3945.36","2959.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3095.13","78.45","","2647.39","1568.87","3176.87","1 through 10","1972.68","3095.13","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","5652.70","4239.52","AETNA [1001]","HB CH AETNA HMO / PPO","3295.52","58.3","","1952.48","1215.31","1952.48","1 through 10","2512.63","4404.02","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","5652.70","4239.52","WELLPOINT [1015]","HB CH WELLPOINT","4404.02","77.91","","2735.63","2146.75","4736.42","1 through 10","2512.63","4404.02","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5652.70","4239.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","3352.05","59.3","","1597.25","1552.67","1756.87","1 through 10","2826.35","4434.54","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5652.70","4239.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4434.54","78.45","","2647.39","1568.87","3176.87","1 through 10","2826.35","4434.54","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","AETNA [1001]","HB CH AETNA HMO / PPO","0.45","58.3","","0.27","0.06","0.53","715","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","0.41","53","","11984.89","2.01","11984.89","1 through 10","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","0.56","73","","0.63","0.63","1.62","20","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","0.77","0.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.40","52.2","","0.25","0.05","0.61","1358","0.26","0.4","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","0.77","0.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","0.40","52.2","","0.28","0.28","0.28","1 through 10","0.26","0.4","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","158.76","158.76","158.76","28","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","167.04","58","","73.10","73.10","73.10","1 through 10","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","167.04","58","","86.00","83.51","86.00","1 through 10","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","180.00","62.5","","94.77","94.77","284.31","49","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.02","44.45","","127.57","127.57","127.57","1 through 10","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","220.53","220.53","220.53","1 through 10","128.02","224.38","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","247.36","247.36","247.36","1 through 10","144","225.94","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","215.26","81.45","215.26","106","144","225.94","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","AETNA [1001]","HB CH AETNA HMO / PPO","194.72","58.3","","184.28","184.28","368.55","45","177.02","317.63","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","211.76","63.4","","215.48","207.35","430.95","18","177.02","317.63","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","193.72","58","","164.13","164.13","164.13","1 through 10","177.02","317.63","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","193.72","58","","193.05","193.05","325.00","1 through 10","177.02","317.63","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","208.75","62.5","","208.00","208.00","624.00","41","177.02","317.63","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","192.72","57.7","","587.93","195.98","587.93","47","28.88","262.02","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","202.07","60.5","","245.05","205.73","411.45","20","28.88","262.02","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","202.07","60.5","","205.73","205.73","205.73","1 through 10","28.88","262.02","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.46","44.45","","249.86","148.07","249.86","1 through 10","28.88","262.02","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.02","78.45","","249.86","148.07","249.86","13","28.88","262.02","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","1 through 10","24.76","196.65","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB NWH TRICARE","196.65","95","","30.45","30.45","30.45","1 through 10","24.76","196.65","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","207.00","155.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.75","59.3","","117.79","117.79","117.79","1 through 10","26.07","162.39","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","154.53","91.58","154.53","1 through 10","26.07","162.39","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","100.36","100.36","100.36","35","21.79","172.9","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","182.00","136.50","TRICARE [160005]","HB NWH TRICARE","172.90","95","","26.79","25.45","26.79","1 through 10","21.79","172.9","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","182.00","136.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.90","44.45","","136.08","136.08","136.08","1 through 10","21.79","172.9","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","182.00","136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.93","59.3","","103.72","103.72","311.16","25","22.93","142.78","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","136.08","80.64","136.08","27","22.93","142.78","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","12","57.42","218.7","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","1 through 10","68","193.91","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","101.48","101.48","1 through 10","68","193.91","percent of total billed charges",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7997.55","","Case rate ($7,764.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,171.25. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8211.55","8211.55","8211.55","1 through 10","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","8537.38","","Case rate ($8,537.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,944.02. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7844.52","7844.52","7844.52","1 through 10","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","MEDICARE [2001]","HB NWH MEDICARE","8537.38","","Case rate ($8,537.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,944.02. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8753.91","728.09","8769.65","39","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7609.32","","Case rate ($7,764.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,171.25. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7824.15","7824.15","7856.04","1 through 10","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7609.32","","Case rate ($7,764.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,171.25. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7835.05","7835.05","7840.35","1 through 10","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","24683.49","18512.62","WELLSENSE [1003]","HB NWH MEDICARE","8537.38","","Case rate ($8,537.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,976.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,118.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,535.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,944.02. The transfer operating threshold is the transfer adjustment factor * $7,976.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.36. The transfer capital threshold is the transfer adjustment factor * $593.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7850.79","7850.79","7850.79","1 through 10","7609.32","8862.5218","other","Inpatient DRG"
"Diabetes With Cc","638","TRIS-DRG","","","","","","","","inpatient","","","27021.80","","TRICARE [160005]","HB NWH TRICARE","4817.83","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($6,754.88). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,070.40, and the first day is paid a rate of $6,140.80. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,070.40, and the first day is paid a rate of $6,140.80. The transfer payment is capped at $6,090.96. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $50,576.32 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.20000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,196.06), capped at $6,090.96. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,070.40, and the first day is paid a rate of $6,140.80. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,070.40, and the first day is paid a rate of $6,140.80. The transfer payment is capped at $6,090.96. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $50,576.32 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.20000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","7894.97","7894.97","7894.97","1 through 10","4817.83","4817.83","other","Inpatient DRGs"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","12820.88","","Case rate ($12,447.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,496.24. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13038.03","13038.03","13038.03","1 through 10","12198.51","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13686.29","","Case rate ($13,686.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,735.07. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12559.37","12559.37","12559.37","1 through 10","12198.51","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","MEDICARE [2001]","HB NWH MEDICARE","13686.29","","Case rate ($13,686.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,735.07. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13899.19","13899.01","13924.17","23","12198.51","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12198.51","","Case rate ($12,447.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,496.24. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12417.18","12417.18","20847.61","1 through 10","12198.51","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","12198.51","","Case rate ($12,447.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,496.24. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14045.40","14045.40","14045.40","1 through 10","12198.51","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","32867.06","24650.29","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12198.51","","Case rate ($12,447.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,786.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,929.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,893.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,496.24. The transfer operating threshold is the transfer adjustment factor * $12,786.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.22. The transfer capital threshold is the transfer adjustment factor * $951.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12413.40","12413.40","12413.40","1 through 10","12198.51","14747.73","other","Inpatient DRG"
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","19859.93","14894.95","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6116.36","6116.36","6116.36","1 through 10","5274.4","6196.4474","case rate",""
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","19859.93","14894.95","MEDICARE [2001]","HB NWH MEDICARE","5382.04","","Case rate ($5,382.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,528.81, add-ons for qualifying new technology services are included. If operating cost exceeds $50,671.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,353.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,970.74. The transfer operating threshold is the transfer adjustment factor * $5,528.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.29. The transfer capital threshold is the transfer adjustment factor * $411.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5980.37","5980.37","5980.37","1 through 10","5274.4","6196.4474","other","Inpatient Replacement Plans DRG"
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13341.06","","Standard inlier is a Case rate ($13,341.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,893.82) for the length of stay and the standard reimbursement.","19724.76","19724.76","19724.76","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14330.96","","Standard inlier is a Case rate ($14,330.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,034.22) for the length of stay and the standard reimbursement.","21188.33","20225.23","21188.33","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8627.793","","Fee schedule rate ($18,762.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8627.793","18762.28","18762.28","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9059.1385","","Fee schedule rate ($19,700.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9059.1385","20638.31","20638.31","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","MASSHEALTH [3001]","HB NWH MEDICAID","5662.71","","Case rate ($6,100.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,530.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,580.48 and the sum of the standard inlier and any outlier amount.","9223.29","624.49","71551.69","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","5662.71","","Case rate ($6,100.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,530.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,580.48 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19020.24","","Fee schedule rate ($19,020.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19020.24","16167.00","19020.24","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","29119.33","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5662.71","","Case rate ($6,100.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,530.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,580.48 and the sum of the standard inlier and any outlier amount.","9223.28","1217.40","9223.28","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","18775.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10382.10","","Standard inlier is a Case rate ($10,382.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,299, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,473.78) for the length of stay and the standard reimbursement.","8305.68","8305.68","8305.68","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","24792.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13341.06","","Standard inlier is a Case rate ($13,341.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,893.82) for the length of stay and the standard reimbursement.","12816.75","12816.75","12816.75","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","24792.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14330.96","","Standard inlier is a Case rate ($14,330.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,034.22) for the length of stay and the standard reimbursement.","13679.55","13679.55","14330.96","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","24792.13","","MASSHEALTH [3001]","HB NWH MEDICAID","5662.71","","Case rate ($6,100.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,530.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9223.29","9223.29","9223.29","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","24792.13","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","7585.12","","Fee schedule rate ($7,585.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5469.36","5469.36","5469.36","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","24792.13","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5662.71","","Case rate ($6,100.67). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,530.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6116.36","927.66","6116.36","12","3857.53","78888.17","case rate",""
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","both","","","2783.00","2087.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2031.59","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","both","","","2783.00","2087.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","209.98","209.98","1 through 10","200.84","2031.59","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000092","CDM","71270","CPT","0352","RC","","","","both","","","2745.00","2058.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2003.85","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000092","CDM","71270","CPT","0352","RC","","","","both","","","2745.00","2058.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","209.98","209.98","1 through 10","200.84","2003.85","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","62","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","287.48","574.96","1 through 10","200.84","1727.91","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","498.06","253.19","506.37","15","200.84","1727.91","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HUMANA [1012]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.40","506.40","506.40","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","516.73","700","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","359.85","359.85","359.85","1 through 10","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","423.35","411.10","423.35","19","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","444.52","444.52","444.52","1 through 10","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","466.52","466.52","1399.56","46","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MOLINA [1014]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.10","419.10","419.10","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1727.91","73","","1263.92","1263.92","1263.92","1 through 10","200.84","1727.91","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","TRICARE [160005]","HB NWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","211.41","211.41","1 through 10","200.84","1727.91","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","208.03","1523.70","96","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","207.18","508.47","67","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1305.23","482.16","1305.23","1 through 10","201.74","1183.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","100","201.74","1183.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","194","201.74","1183.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","441.81","229.99","459.97","76","201.74","1183.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","2410.80","32","201.74","1183.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","841.23","35.54","","801.79","801.79","1048.79","29","201.74","1183.5","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","62","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","287.48","574.96","1 through 10","200.84","1635.93","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","498.06","253.19","506.37","15","200.84","1635.93","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HUMANA [1012]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.40","506.40","506.40","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","516.73","700","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","359.85","359.85","359.85","1 through 10","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","423.35","411.10","423.35","19","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","444.52","444.52","444.52","1 through 10","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","466.52","466.52","1399.56","46","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MOLINA [1014]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.10","419.10","419.10","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1635.93","73","","1263.92","1263.92","1263.92","1 through 10","200.84","1635.93","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","TRICARE [160005]","HB NWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","211.41","211.41","1 through 10","200.84","1635.93","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","208.03","1523.70","96","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","207.18","508.47","67","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1305.23","482.16","1305.23","1 through 10","201.74","1120.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","100","201.74","1120.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","610.66","194","201.74","1120.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","441.81","229.99","459.97","76","201.74","1120.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","2410.80","32","201.74","1120.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","796.45","35.54","","801.79","801.79","1048.79","29","201.74","1120.5","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0350","RC","","","","inpatient","","","1953.00","1464.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1093.68","56","","1112.81","1112.81","1112.81","1 through 10","1093.68","1378.82","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","61","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.17","117.59","355.17","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1425.69","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","23","112.51","1425.69","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1043","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","264.34","264.34","264.34","1 through 10","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","310.99","301.99","310.99","17","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","326.54","301.99","326.54","1 through 10","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","342.71","332.78","342.71","44","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","1425.69","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","262.40","115","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","95","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","694.10","35.54","","865.18","865.18","865.18","1 through 10","112.51","1425.69","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1076.73","1076.73","1076.73","1 through 10","112.51","976.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","121","112.51","976.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","244","112.51","976.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","103","112.51","976.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","806.70","28","112.51","976.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","976.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.10","35.54","","661.42","661.42","865.18","44","112.51","976.5","percent of total billed charges",""
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","163.30","163.30","163.30","1 through 10","17.84","253.65","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","AETNA [1001]","HB CH AETNA HMO / PPO","395.27","58.3","","373.65","373.65","373.65","11","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","494.94","73","","155.41","155.41","155.41","1 through 10","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","TRICARE [160005]","HB NWH TRICARE","644.10","95","","129.51","123.03","129.51","1 through 10","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","402.05","59.3","","386.17","386.17","386.17","125","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","531.89","78.45","","659.00","659.00","659.00","1 through 10","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.37","44.45","","300.24","300.24","659.00","1 through 10","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","531.89","78.45","","506.64","300.24","506.64","115","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.37","44.45","","506.64","506.64","506.64","1 through 10","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","550.00","412.50","AETNA [1001]","HB CH AETNA HMO / PPO","320.65","58.3","","303.35","303.35","606.70","14","99.6","522.5","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","550.00","412.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","326.15","59.3","","296.87","296.87","296.87","1 through 10","214.46","463.87","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","550.00","412.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","431.48","78.45","","289.88","165.98","393.56","1 through 10","214.46","463.87","percent of total billed charges",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","32320.91","24240.68","MEDICARE [2001]","HB NWH MEDICARE","11522.89","","Case rate ($11,522.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,765.69, add-ons for qualifying new technology services are included. If operating cost exceeds $55,907.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,742.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,722.03. The transfer operating threshold is the transfer adjustment factor * $10,765.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $800.86. The transfer capital threshold is the transfer adjustment factor * $800.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11726.91","11726.91","11748.00","1 through 10","10270.28","11961.7344","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","32320.91","24240.68","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10270.28","","Case rate ($10,479.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,765.69, add-ons for qualifying new technology services are included. If operating cost exceeds $55,907.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,742.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,679.02. The transfer operating threshold is the transfer adjustment factor * $10,765.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $800.86. The transfer capital threshold is the transfer adjustment factor * $800.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10473.34","10473.34","10473.34","1 through 10","10270.28","11961.7344","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","39295.78","29471.83","MEDICARE [2001]","HB NWH MEDICARE","18529.54","","Case rate ($18,529.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,034.87, add-ons for qualifying new technology services are included. If operating cost exceeds $64,177.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,357.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,113.53. The transfer operating threshold is the transfer adjustment factor * $19,034.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,416.01. The transfer capital threshold is the transfer adjustment factor * $1,416.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20151.30","10795.19","20187.79","15","18158.95","21953.76","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","39295.78","29471.83","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","18158.95","","Case rate ($18,529.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,034.87, add-ons for qualifying new technology services are included. If operating cost exceeds $64,177.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,357.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,113.53. The transfer operating threshold is the transfer adjustment factor * $19,034.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,416.01. The transfer capital threshold is the transfer adjustment factor * $1,416.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18022.88","18022.88","18022.88","1 through 10","18158.95","21953.76","other","Inpatient DRG"
"Digestive Malignancy Without Cc/McC","376","MS-DRG","","","","","","","","inpatient","","","23117.17","17337.88","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8008.07","","Case rate ($8,008.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,226.46, add-ons for qualifying new technology services are included. If operating cost exceeds $53,368.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,553.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,396.10. The transfer operating threshold is the transfer adjustment factor * $8,226.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.97. The transfer capital threshold is the transfer adjustment factor * $611.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7224.26","7224.26","7224.26","1 through 10","7847.91","8731.987","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","46985.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26978.76","","Standard inlier is a Case rate ($26,978.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,325, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,829.74) for the length of stay and the standard reimbursement.","19223.92","19223.92","19223.92","1 through 10","7396.82","107617.57","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","46985.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28980.57","","Standard inlier is a Case rate ($28,980.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,325, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,113.67) for the length of stay and the standard reimbursement.","4113.66","4113.66","28980.56","1 through 10","7396.82","107617.57","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","46985.99","","MASSHEALTH [3001]","HB NWH MEDICAID","12873.32","","Case rate ($13,868.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,298.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,107.75 and the sum of the standard inlier and any outlier amount.","2831.14","2831.14","2831.14","1 through 10","7396.82","107617.57","case rate",""
"Digestive Malignancy,MINOR","240","DRG","","","","","","","","inpatient","","","29351.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18386.40","","Standard inlier is a Case rate ($18,386.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,609.87) for the length of stay and the standard reimbursement.","18386.39","18386.39","18386.39","1 through 10","7396.82","107617.57","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","29511.37","","MASSHEALTH [3001]","HB NWH MEDICAID","8327.85","","Case rate ($8,971.94). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,401.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1250.56","1250.56","1250.56","1 through 10","7396.82","107617.57","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","29511.37","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","8980.49","","Fee schedule rate ($8,980.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8980.42","8980.42","8980.42","1 through 10","7396.82","107617.57","case rate",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","AETNA [1001]","HB CH AETNA HMO / PPO","172.57","58.3","","163.30","163.30","163.30","1 through 10","17.84","651.21","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","216.08","73","","21.84","21.84","21.84","1 through 10","17.84","651.21","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","TRICARE [160005]","HB NWH TRICARE","281.20","95","","147.71","140.32","147.71","1 through 10","17.84","651.21","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","WELLPOINT [1015]","HB CH WELLPOINT","230.61","77.91","","226.83","226.83","514.83","34","17.84","651.21","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","175.53","59.3","","168.77","168.77","168.77","115","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.57","44.45","","131.21","131.21","288.00","1 through 10","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","232.21","78.45","","221.41","131.21","221.41","112","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","232.00","174.00","AETNA [1001]","HB CH AETNA HMO / PPO","135.26","58.3","","128.14","128.14","128.14","11","17.84","512.75","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","outpatient","","","232.00","174.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","182.00","78.45","","122.46","70.11","166.07","1 through 10","69.66","224.8","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","both","","","137.00","102.75","AETNA [1001]","HB CH AETNA HMO / PPO","79.87","58.3","","75.41","75.41","75.41","1 through 10","13.01","130.15","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","outpatient","","","137.00","102.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.24","59.3","","77.94","77.94","77.94","1 through 10","13.69","107.48","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","84.29","84.29","84.29","1 through 10","50.42","149.06","percent of total billed charges",""
"Dilate Sphincter Anal W/Anes","PX-75000206","CDM","45905","CPT","0750","RC","","","","outpatient","","","5034.00","3775.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2522.03","50.1","","1586.56","1586.56","1586.56","1 through 10","2013.6","3949.17","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","AETNA [1001]","HB CH AETNA HMO / PPO","261.77","58.3","","48.90","46.54","48.90","1 through 10","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.97","53","","91.65","91.65","91.65","1 through 10","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","260.42","58","","51.23","51.23","51.23","1 through 10","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","280.63","62.5","","65.12","36.89","65.12","1 through 10","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.77","73","","46.29","46.29","46.29","1 through 10","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","both","","","449.00","336.75","WELLPOINT [1015]","HB CH WELLPOINT","349.82","77.91","","64.65","45.40","120.92","18","199.58","349.82","percent of total billed charges",""
"DILATOR AND SHEATH BX/6EA","SUP-ITM-10266913","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","449.00","336.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","352.24","78.45","","276.77","63.10","312.43","11","224.5","352.24","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","513.45","385.09","WELLPOINT [1015]","HB CH WELLPOINT","400.03","77.91","","582.67","582.67","582.67","1 through 10","228.23","400.03","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","513.45","385.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.80","78.45","","394.74","331.66","1115.07","1 through 10","256.73","402.8","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","579.27","434.45","WELLPOINT [1015]","HB CH WELLPOINT","451.31","77.91","","582.67","582.67","582.67","1 through 10","257.49","451.31","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","579.27","434.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","454.44","78.45","","394.74","331.66","1115.07","1 through 10","289.64","454.44","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","582.67","582.67","582.67","1 through 10","298.7","523.56","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","394.74","331.66","1115.07","1 through 10","336","527.18","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","89.59","89.59","89.59","1 through 10","13.27","153.9","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","92.59","91.34","92.59","1 through 10","13.98","127.09","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","121.47","45.68","121.47","1 through 10","13.98","127.09","percent of total billed charges",""
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","both","","","110.00","82.50","MEDICARE [2001]","HB NWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","728.09","3144.34","1 through 10","58.3","7249","other","OPPS APC"
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","131.00","131.00","131.00","21","48.9","4642","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","AETNA [1001]","HB CH AETNA HMO / PPO","5713.40","58.3","","2190.90","412.50","9264.59","16","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5684.00","58","","1903.20","1903.20","3826.66","1 through 10","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6125.00","62.5","","2186.25","2186.25","2186.25","32","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7154.00","73","","5556.60","5556.60","5556.60","1 through 10","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","WELLPOINT [1015]","HB CH WELLPOINT","7635.18","77.91","","1955.15","885.83","3150.40","26","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5811.40","59.3","","831.03","253.22","2394.88","18","4900","7688.1","percent of total billed charges",""
"DISC CERVICAL 13X15 H4.5 IMPLANT MOBI-C","SUP-ITM-10321918","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7688.10","78.45","","2481.69","1563.74","8149.28","1 through 10","4900","7688.1","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","AETNA [1001]","HB CH AETNA HMO / PPO","5713.40","58.3","","2190.90","412.50","9264.59","16","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5684.00","58","","1903.20","1903.20","3826.66","1 through 10","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6125.00","62.5","","2186.25","2186.25","2186.25","32","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7154.00","73","","5556.60","5556.60","5556.60","1 through 10","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","WELLPOINT [1015]","HB CH WELLPOINT","7635.18","77.91","","1955.15","885.83","3150.40","26","4356.1","7635.18","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5811.40","59.3","","831.03","253.22","2394.88","18","4900","7688.1","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7688.10","78.45","","2481.69","1563.74","8149.28","1 through 10","4900","7688.1","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","AETNA [1001]","HB CH AETNA HMO / PPO","362.63","58.3","","3384.99","3384.99","3646.94","1 through 10","329.66","2109.35","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","394.35","63.4","","1370.42","1370.42","1370.42","1 through 10","329.66","2109.35","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","MEDICARE [2001]","HB NWH MEDICARE","2047.91","","APC Price ($2,047.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","2047.91","2047.91","1 through 10","329.66","2109.35","other","OPPS APC"
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.19","","Case rate ($189.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","267.51","267.51","267.51","1 through 10","189.19","567.68","other","ASC "
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.19","","Case rate ($189.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","273.57","267.89","273.57","1 through 10","189.19","567.68","other","ASC "
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","368.85","59.3","","3498.42","3498.42","3498.42","1 through 10","189.19","567.68","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","358.89","57.7","","6883.41","6883.41","6883.41","1 through 10","189.19","567.68","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","487.96","78.45","","4589.74","4589.74","4589.74","1 through 10","189.19","567.68","percent of total billed charges",""
"Disopyramide Serum","PX-30003016","CDM","80299","CPT","0301","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","121.91","121.91","121.91","1 through 10","18.27","108.3","percent of total billed charges",""
"Disopyramide Serum","PX-30003016","CDM","80299","CPT","0301","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","125.99","125.99","125.99","1 through 10","14.12","89.43","percent of total billed charges",""
"Disopyramide Serum","PX-30003016","CDM","80299","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","165.29","97.95","215.00","1 through 10","14.12","89.43","percent of total billed charges",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","55388.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","48426.93","","Standard inlier is a Case rate ($48,426.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $61,328, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,874.39) for the length of stay and the standard reimbursement.","48426.93","48426.93","48426.93","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","55388.34","","MASSHEALTH [3001]","HB NWH MEDICAID","23081.51","","Case rate ($24,866.68). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $67,296.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35722.57","35722.57","35722.57","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","55388.34","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","54331.11","","Fee schedule rate ($54,331.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54331.11","54331.11","54331.11","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","24384.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27902.97","","Standard inlier is a Case rate ($27,902.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,274, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,960.94) for the length of stay and the standard reimbursement.","27902.97","27902.97","27902.97","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","24384.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29973.36","","Standard inlier is a Case rate ($29,973.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,274, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,254.59) for the length of stay and the standard reimbursement.","29973.35","8509.18","29973.35","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","24384.40","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","12444.94","","Case rate ($13,407.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,837.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,040.24 and the sum of the standard inlier and any outlier amount.","16802.42","16802.42","16802.42","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","30702.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16385.01","","Standard inlier is a Case rate ($16,385.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,325.78) for the length of stay and the standard reimbursement.","16385.01","16385.01","16385.01","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","30702.64","","MASSHEALTH [3001]","HB NWH MEDICAID","6229.32","","Case rate ($6,711.11). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,141.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6728.37","6728.37","6728.37","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","30702.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","16879.37","","Fee schedule rate ($16,879.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16879.37","16879.37","16879.37","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","39597.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20146.43","","Standard inlier is a Case rate ($20,146.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,859.86) for the length of stay and the standard reimbursement.","20146.42","20146.42","20146.42","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","39597.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21641.28","","Standard inlier is a Case rate ($21,641.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,071.89) for the length of stay and the standard reimbursement.","21641.28","21641.28","21641.28","1 through 10","2488","99314.74","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","39597.48","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","16850.20","","Fee schedule rate ($16,850.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16850.20","16850.20","16850.20","1 through 10","2488","99314.74","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","31546.58","23659.93","MEDICARE [2001]","HB NWH MEDICARE","9195.64","","Case rate ($9,195.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,591.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,733.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,581.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,556.53. The transfer operating threshold is the transfer adjustment factor * $8,591.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.11. The transfer capital threshold is the transfer adjustment factor * $639.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9238.15","9238.15","9238.15","1 through 10","8196.01","9908.8","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","31546.58","23659.93","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8196.01","","Case rate ($8,363.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,591.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,733.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,581.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,724.17. The transfer operating threshold is the transfer adjustment factor * $8,591.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.11. The transfer capital threshold is the transfer adjustment factor * $639.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8265.82","8265.82","8265.82","1 through 10","8196.01","9908.8","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","31546.58","23659.93","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8196.01","","Case rate ($8,363.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,591.37, add-ons for qualifying new technology services are included. If operating cost exceeds $53,733.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,581.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,724.17. The transfer operating threshold is the transfer adjustment factor * $8,591.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.11. The transfer capital threshold is the transfer adjustment factor * $639.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8244.22","8244.22","8244.22","1 through 10","8196.01","9908.8","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","30860.73","23145.55","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","12067.39","12067.39","12067.39","1 through 10","15238.17","18422.6","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","30860.73","23145.55","MEDICARE [2001]","HB NWH MEDICARE","15549.15","","Case rate ($15,549.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,973.20, add-ons for qualifying new technology services are included. If operating cost exceeds $61,115.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,130.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,360.90. The transfer operating threshold is the transfer adjustment factor * $15,973.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.25. The transfer capital threshold is the transfer adjustment factor * $1,188.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18042.30","18042.06","18074.73","1 through 10","15238.17","18422.6","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","30860.73","23145.55","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15238.17","","Case rate ($15,549.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,973.20, add-ons for qualifying new technology services are included. If operating cost exceeds $61,115.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,130.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,360.90. The transfer operating threshold is the transfer adjustment factor * $15,973.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.25. The transfer capital threshold is the transfer adjustment factor * $1,188.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10074.07","10074.07","10074.07","1 through 10","15238.17","18422.6","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/McC","443","MS-DRG","","","","","","","","inpatient","","","23139.24","17354.43","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6062.15","","Case rate ($6,062.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,227.48, add-ons for qualifying new technology services are included. If operating cost exceeds $51,369.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,405.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,598.89. The transfer operating threshold is the transfer adjustment factor * $6,227.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.26. The transfer capital threshold is the transfer adjustment factor * $463.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6611.25","6611.25","6611.25","1 through 10","5940.91","6949.0003","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7506.75","","Case rate ($7,288.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,486.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,629.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,498.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,731.15. The transfer operating threshold is the transfer adjustment factor * $7,486.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.95. The transfer capital threshold is the transfer adjustment factor * $556.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7343.28","7343.28","7343.28","1 through 10","7142.35","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7008.46","7008.46","7008.46","1 through 10","7142.35","8634.92","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","FALLON HEALTH [1008]","HB NWH MEDICARE","7288.11","","Case rate ($7,288.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,486.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,629.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,498.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,731.15. The transfer operating threshold is the transfer adjustment factor * $7,486.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.95. The transfer capital threshold is the transfer adjustment factor * $556.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7332.28","7332.28","7332.28","1 through 10","7142.35","8634.92","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","MEDICARE [2001]","HB NWH MEDICARE","7288.11","","Case rate ($7,288.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,486.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,629.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,498.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,731.15. The transfer operating threshold is the transfer adjustment factor * $7,486.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.95. The transfer capital threshold is the transfer adjustment factor * $556.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8224.66","1142.68","8224.66","11","7142.35","8634.92","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7142.35","","Case rate ($7,288.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,486.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,629.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,498.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,731.15. The transfer operating threshold is the transfer adjustment factor * $7,486.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.95. The transfer capital threshold is the transfer adjustment factor * $556.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7339.28","7339.28","7362.51","1 through 10","7142.35","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","24035.15","18026.36","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7142.35","","Case rate ($7,288.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,486.86, add-ons for qualifying new technology services are included. If operating cost exceeds $52,629.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,498.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,731.15. The transfer operating threshold is the transfer adjustment factor * $7,486.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.95. The transfer capital threshold is the transfer adjustment factor * $556.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7354.78","7354.78","7354.78","1 through 10","7142.35","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","40638.66","30478.99","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14547.65","","Case rate ($14,123.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,509.11, add-ons for qualifying new technology services are included. If operating cost exceeds $59,651.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,044.60. The transfer operating threshold is the transfer adjustment factor * $14,509.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.34. The transfer capital threshold is the transfer adjustment factor * $1,079.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14902.32","14902.32","14902.32","1 through 10","13841.45","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","40638.66","30478.99","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15529.61","","Case rate ($15,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,509.11, add-ons for qualifying new technology services are included. If operating cost exceeds $59,651.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,450.28. The transfer operating threshold is the transfer adjustment factor * $14,509.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.34. The transfer capital threshold is the transfer adjustment factor * $1,079.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14351.18","14351.18","14351.18","1 through 10","13841.45","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","40638.66","30478.99","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","2655.56","2655.56","2655.56","1 through 10","13841.45","16452.3293","case rate",""
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","40638.66","30478.99","MEDICARE [2001]","HB NWH MEDICARE","15529.61","","Case rate ($15,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,509.11, add-ons for qualifying new technology services are included. If operating cost exceeds $59,651.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,450.28. The transfer operating threshold is the transfer adjustment factor * $14,509.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.34. The transfer capital threshold is the transfer adjustment factor * $1,079.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15907.18","15878.64","15907.18","1 through 10","13841.45","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","40638.66","30478.99","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13841.45","","Case rate ($14,123.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,509.11, add-ons for qualifying new technology services are included. If operating cost exceeds $59,651.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,044.60. The transfer operating threshold is the transfer adjustment factor * $14,509.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.34. The transfer capital threshold is the transfer adjustment factor * $1,079.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14212.86","14212.86","14212.86","1 through 10","13841.45","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","17873.02","13404.76","MEDICARE [2001]","HB NWH MEDICARE","5383.76","","Case rate ($5,383.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,530.59, add-ons for qualifying new technology services are included. If operating cost exceeds $50,672.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,353.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,972.34. The transfer operating threshold is the transfer adjustment factor * $5,530.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.42. The transfer capital threshold is the transfer adjustment factor * $411.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5881.18","1458.38","5881.18","1 through 10","5276.08","6378.67","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","17873.02","13404.76","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","5276.08","","Case rate ($5,383.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,530.59, add-ons for qualifying new technology services are included. If operating cost exceeds $50,672.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,353.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,972.34. The transfer operating threshold is the transfer adjustment factor * $5,530.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $411.42. The transfer capital threshold is the transfer adjustment factor * $411.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6016.84","6016.84","6016.84","1 through 10","5276.08","6378.67","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","53003.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","59422.67","","Standard inlier is a Case rate ($59,422.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $68,397, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,434.80) for the length of stay and the standard reimbursement.","56721.64","56721.64","56721.64","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","53003.25","","MASSHEALTH [3001]","HB NWH MEDICAID","27588.14","","Case rate ($29,721.86). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $72,151.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11498.57","11498.57","11498.57","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","53003.25","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","27588.14","","Case rate ($29,721.86). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $72,151.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24980.79","","Standard inlier is a Case rate ($24,980.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,276, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,546.12) for the length of stay and the standard reimbursement.","52571.32","52571.32","52571.32","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26834.35","","Standard inlier is a Case rate ($26,834.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,276, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,809.02) for the length of stay and the standard reimbursement.","25617.02","25617.02","26834.34","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Fee schedule rate ($28,263.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11662.6656","28263.60","28263.60","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12245.7392","","Fee schedule rate ($29,676.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12245.7392","24871.73","24871.73","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","MASSHEALTH [3001]","HB NWH MEDICAID","10645.71","","Case rate ($11,469.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,899.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11498.57","11498.57","11498.57","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23900.74","","Fee schedule rate ($23,900.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23900.74","23900.74","23900.74","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","10645.71","","Case rate ($11,469.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,899.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18287.24","18287.24","18287.24","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","31423.77","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","10645.71","","Case rate ($11,469.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,899.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11498.56","1020.93","14373.21","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","17208.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12603.16","","Standard inlier is a Case rate ($12,603.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,789.07) for the length of stay and the standard reimbursement.","12603.16","12603.16","12603.16","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","17208.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13538.31","","Standard inlier is a Case rate ($13,538.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,921.71) for the length of stay and the standard reimbursement.","13538.30","12923.57","13538.30","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","17208.99","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Fee schedule rate ($11,662.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11662.6656","11662.66","11662.66","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16410.34","","Standard inlier is a Case rate ($16,410.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,484, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,329.51) for the length of stay and the standard reimbursement.","16410.34","16410.34","16410.34","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17627.98","","Standard inlier is a Case rate ($17,627.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,484, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,502.22) for the length of stay and the standard reimbursement.","16826.70","16826.70","17627.97","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Fee schedule rate ($28,263.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11662.6656","14706.16","15295.52","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","MASSHEALTH [3001]","HB NWH MEDICAID","6488.64","","Case rate ($6,990.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,420.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7008.46","7008.46","7008.46","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11213.36","","Fee schedule rate ($11,213.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7120.59","7120.59","7120.59","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","24839.21","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6488.64","","Case rate ($6,990.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,420.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7008.46","7008.46","7008.46","1 through 10","4591.17","121933.91","case rate",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","30650.99","22988.24","MEDICARE [2001]","HB NWH MEDICARE","1351.10","","Case rate ($1,351.10) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15238.08","15238.08","17693.71","1 through 10","1351.1","20184.07","other","Inpatient Psych"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","30650.99","22988.24","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1351.10","","Case rate ($1,351.10) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15807.30","15807.30","15807.30","1 through 10","1351.1","20184.07","other","Inpatient Psych"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25418.67","19064.00","MEDICARE [2001]","HB NWH MEDICARE","10425.49","","Case rate ($10,425.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,740.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,882.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,666.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,700.89. The transfer operating threshold is the transfer adjustment factor * $9,740.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.59. The transfer capital threshold is the transfer adjustment factor * $724.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10350.66","10350.53","10369.27","1 through 10","9292.17","11234.02","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25418.67","19064.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9292.17","","Case rate ($9,481.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,740.39, add-ons for qualifying new technology services are included. If operating cost exceeds $54,882.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,666.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,757.21. The transfer operating threshold is the transfer adjustment factor * $9,740.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.59. The transfer capital threshold is the transfer adjustment factor * $724.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9253.00","9253.00","9258.00","1 through 10","9292.17","11234.02","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","TRIS-DRG","","","","","","","","inpatient","","","17658.54","","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","8100.04","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($11,356.74). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $55,178.19 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($7,832.24), capped at $10,240.52. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $55,178.19 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","10951.76","10951.76","10951.76","1 through 10","8100.04","8100.04","other","Inpatient DRGs"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14910.86","","Case rate ($14,476.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,871.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,013.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,048.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,370.27. The transfer operating threshold is the transfer adjustment factor * $14,871.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.28. The transfer capital threshold is the transfer adjustment factor * $1,106.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15099.09","15099.09","15099.09","1 through 10","14187.03","16657.0316","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15917.34","","Case rate ($15,917.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,871.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,013.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,048.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,811.05. The transfer operating threshold is the transfer adjustment factor * $14,871.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.28. The transfer capital threshold is the transfer adjustment factor * $1,106.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15847.43","15847.43","15847.43","1 through 10","14187.03","16657.0316","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10661.99","10661.99","10661.99","1 through 10","14187.03","16657.0316","case rate",""
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","MEDICARE [2001]","HB NWH MEDICARE","15917.34","","Case rate ($15,917.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,871.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,013.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,048.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,811.05. The transfer operating threshold is the transfer adjustment factor * $14,871.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.28. The transfer capital threshold is the transfer adjustment factor * $1,106.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16076.21","972.84","16105.11","15","14187.03","16657.0316","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14187.03","","Case rate ($14,476.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,871.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,013.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,048.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,370.27. The transfer operating threshold is the transfer adjustment factor * $14,871.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.28. The transfer capital threshold is the transfer adjustment factor * $1,106.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16256.22","16256.22","16256.22","1 through 10","14187.03","16657.0316","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","41644.32","31233.24","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14187.03","","Case rate ($14,476.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,871.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,013.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,048.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,370.27. The transfer operating threshold is the transfer adjustment factor * $14,871.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.28. The transfer capital threshold is the transfer adjustment factor * $1,106.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14399.57","14399.57","14399.57","1 through 10","14187.03","16657.0316","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","31152.62","23364.46","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7167.66","","Case rate ($7,167.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,363.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,505.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,489.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,619.92. The transfer operating threshold is the transfer adjustment factor * $7,363.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.75. The transfer capital threshold is the transfer adjustment factor * $547.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36.64","36.64","36.64","1 through 10","7024.31","7884.4997","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","31152.62","23364.46","MEDICARE [2001]","HB NWH MEDICARE","7167.66","","Case rate ($7,167.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,363.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,505.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,489.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,619.92. The transfer operating threshold is the transfer adjustment factor * $7,363.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $547.75. The transfer capital threshold is the transfer adjustment factor * $547.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7609.57","7609.57","7609.57","1 through 10","7024.31","7884.4997","other","Inpatient Replacement Plans DRG"
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","AETNA [1001]","HB CH AETNA HMO / PPO","2605.24","58.3","","464.71","67.87","1012.10","221","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2605.24","58.3","","293.04","293.04","293.04","11","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2368.40","53","","983.89","983.89","983.89","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2591.83","58","","677.18","677.18","677.18","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2792.93","62.5","","46.58","46.58","46.58","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3262.14","73","","747.15","747.15","747.15","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.33","44.45","","1141.67","481.21","1141.67","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.33","44.45","","76.54","76.54","76.54","1 through 10","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","WELLPOINT [1015]","HB CH WELLPOINT","3481.55","77.91","","273.64","94.28","1367.51","138","1986.33","3481.55","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2649.93","59.3","","720.78","230.14","2010.94","427","2234.34","3505.68","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2649.93","59.3","","344.45","344.45","344.45","1 through 10","2234.34","3505.68","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3505.68","78.45","","1120.13","1120.13","1120.13","1 through 10","2234.34","3505.68","percent of total billed charges",""
"DISTAL PLATE 10 HOLE 172MM LEG AXSOS SS LOCKING METAPHYSEAL MEDIAL TIBIA RT REPROCESSED","SUP-ITM-10034237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3505.68","78.45","","456.17","105.33","1284.66","242","2234.34","3505.68","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","AETNA [1001]","HB CH AETNA HMO / PPO","2484.15","58.3","","464.71","67.87","1012.10","221","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2484.15","58.3","","293.04","293.04","293.04","11","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2258.32","53","","983.89","983.89","983.89","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2471.37","58","","677.18","677.18","677.18","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2663.11","62.5","","46.58","46.58","46.58","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3110.52","73","","747.15","747.15","747.15","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.01","44.45","","1141.67","481.21","1141.67","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.01","44.45","","76.54","76.54","76.54","1 through 10","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","WELLPOINT [1015]","HB CH WELLPOINT","3319.73","77.91","","273.64","94.28","1367.51","138","1894.01","3319.73","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","2526.76","59.3","","720.78","230.14","2010.94","427","2130.49","3342.74","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2526.76","59.3","","344.45","344.45","344.45","1 through 10","2130.49","3342.74","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3342.74","78.45","","1120.13","1120.13","1120.13","1 through 10","2130.49","3342.74","percent of total billed charges",""
"DISTAL PLATE 2.7MM 3.5 139 8 HOLE BONE VARIAX TITANIUM LOCKING MEDIAL","SUP-ITM-10144736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3342.74","78.45","","456.17","105.33","1284.66","242","2130.49","3342.74","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","AETNA [1001]","HB CH AETNA HMO / PPO","4002.11","58.3","","464.71","67.87","1012.10","221","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4002.11","58.3","","293.04","293.04","293.04","11","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3638.28","53","","983.89","983.89","983.89","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3981.51","58","","677.18","677.18","677.18","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4290.43","62.5","","46.58","46.58","46.58","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5011.22","73","","747.15","747.15","747.15","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3051.35","44.45","","1141.67","481.21","1141.67","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3051.35","44.45","","76.54","76.54","76.54","1 through 10","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","both","","","6864.68","5148.51","WELLPOINT [1015]","HB CH WELLPOINT","5348.27","77.91","","273.64","94.28","1367.51","138","3051.35","5348.27","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6864.68","5148.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","4070.76","59.3","","720.78","230.14","2010.94","427","3432.34","5385.34","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6864.68","5148.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4070.76","59.3","","344.45","344.45","344.45","1 through 10","3432.34","5385.34","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6864.68","5148.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5385.34","78.45","","1120.13","1120.13","1120.13","1 through 10","3432.34","5385.34","percent of total billed charges",""
"DISTAL PLATE 274MM 12 HOLE BONE LATERAL FEMORAL RIGHT","SUP-ITM-10144636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6864.68","5148.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5385.34","78.45","","456.17","105.33","1284.66","242","3432.34","5385.34","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","AETNA [1001]","HB CH AETNA HMO / PPO","1698.28","58.3","","464.71","67.87","1012.10","221","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1698.28","58.3","","293.04","293.04","293.04","11","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.89","53","","983.89","983.89","983.89","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1689.54","58","","677.18","677.18","677.18","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1820.63","62.5","","46.58","46.58","46.58","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2126.49","73","","747.15","747.15","747.15","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.83","44.45","","1141.67","481.21","1141.67","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.83","44.45","","76.54","76.54","76.54","1 through 10","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","WELLPOINT [1015]","HB CH WELLPOINT","2269.52","77.91","","273.64","94.28","1367.51","138","1294.83","2269.52","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1727.41","59.3","","720.78","230.14","2010.94","427","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1727.41","59.3","","344.45","344.45","344.45","1 through 10","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2285.25","78.45","","1120.13","1120.13","1120.13","1 through 10","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2285.25","78.45","","456.17","105.33","1284.66","242","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","AETNA [1001]","HB CH AETNA HMO / PPO","4088.25","58.3","","464.71","67.87","1012.10","221","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4088.25","58.3","","293.04","293.04","293.04","11","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3716.59","53","","983.89","983.89","983.89","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4067.22","58","","677.18","677.18","677.18","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4382.78","62.5","","46.58","46.58","46.58","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5119.08","73","","747.15","747.15","747.15","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3117.03","44.45","","1141.67","481.21","1141.67","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3117.03","44.45","","76.54","76.54","76.54","1 through 10","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","both","","","7012.44","5259.33","WELLPOINT [1015]","HB CH WELLPOINT","5463.39","77.91","","273.64","94.28","1367.51","138","3117.03","5463.39","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7012.44","5259.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","4158.38","59.3","","720.78","230.14","2010.94","427","3506.22","5501.26","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7012.44","5259.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4158.38","59.3","","344.45","344.45","344.45","1 through 10","3506.22","5501.26","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7012.44","5259.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5501.26","78.45","","1120.13","1120.13","1120.13","1 through 10","3506.22","5501.26","percent of total billed charges",""
"DISTAL PLATE 310MM 14 HOLE BONE LATERAL FEMORAL LEFT","SUP-ITM-10140096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7012.44","5259.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5501.26","78.45","","456.17","105.33","1284.66","242","3506.22","5501.26","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","AETNA [1001]","HB CH AETNA HMO / PPO","1764.74","58.3","","1530.90","1160.93","1884.08","89","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1604.31","53","","5253.92","5253.92","5253.92","1 through 10","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1755.66","58","","12181.47","12181.47","12181.47","1 through 10","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1891.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1345.50","44.45","","1910.74","891.94","1910.74","1 through 10","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.00","2270.25","WELLPOINT [1015]","HB CH WELLPOINT","2358.34","77.91","","1829.79","1561.50","2617.12","88","1345.5","2358.34","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.00","2270.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1795.01","59.3","","1359.46","1201.30","1689.00","61","1513.5","2374.68","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.00","2270.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1795.01","59.3","","1718.92","1718.92","1718.92","1 through 10","1513.5","2374.68","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT WIDE","SUP-ITM-10130531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.00","2270.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2374.68","78.45","","1910.74","1019.06","2344.84","74","1513.5","2374.68","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","464.71","67.87","1012.10","221","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1136.85","58.3","","293.04","293.04","293.04","11","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","983.89","983.89","983.89","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1131.00","58","","677.18","677.18","677.18","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1218.75","62.5","","46.58","46.58","46.58","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","747.15","747.15","747.15","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","1141.67","481.21","1141.67","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","76.54","76.54","76.54","1 through 10","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","273.64","94.28","1367.51","138","866.78","1519.25","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","720.78","230.14","2010.94","427","975","1529.78","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1156.35","59.3","","344.45","344.45","344.45","1 through 10","975","1529.78","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","1120.13","1120.13","1120.13","1 through 10","975","1529.78","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","456.17","105.33","1284.66","242","975","1529.78","percent of total billed charges",""
"Diverticulitis And Diverticulosis,EXTREME","244","DRG","","","","","","","","inpatient","","","36882.16","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","18265.29","","Case rate ($19,677.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,107.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19728.57","19728.57","19728.57","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","23797.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17543.71","","Standard inlier is a Case rate ($17,543.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,490.26) for the length of stay and the standard reimbursement.","26526.23","26526.23","26526.23","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","23797.46","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10454.97","","Fee schedule rate ($23,485.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10454.97","23485.58","23485.58","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","23797.46","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","25833.89","","Fee schedule rate ($25,833.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25833.89","25833.89","25833.89","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","23797.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11036.02","","Fee schedule rate ($11,036.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11036.02","11036.02","11036.02","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","23797.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23522.74","","Fee schedule rate ($23,522.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23522.74","23522.74","23522.74","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12500.20","","Standard inlier is a Case rate ($12,500.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,774.45) for the length of stay and the standard reimbursement.","12500.19","12500.19","12500.19","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13427.71","","Standard inlier is a Case rate ($13,427.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,906.01) for the length of stay and the standard reimbursement.","13427.70","12817.35","13427.70","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10454.97","","Fee schedule rate ($10,454.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10454.97","10454.98","10454.98","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","MASSHEALTH [3001]","HB NWH MEDICAID","4320.43","","Case rate ($4,654.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,084.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4845.07","4845.07","4845.07","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6004.52","","Fee schedule rate ($6,004.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6004.52","6004.52","6004.52","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","15860.76","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4320.43","","Case rate ($4,654.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,084.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4666.55","4666.55","4666.55","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","15679.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12500.20","","Standard inlier is a Case rate ($12,500.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,774.45) for the length of stay and the standard reimbursement.","15591.19","15589.74","16331.89","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","15679.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13427.71","","Standard inlier is a Case rate ($13,427.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,906.01) for the length of stay and the standard reimbursement.","17543.71","16747.31","17543.71","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","15679.48","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10454.97","","Fee schedule rate ($13,992.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10454.97","13992.08","13992.08","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","15679.48","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10977.665","","Fee schedule rate ($14,691.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10977.665","14691.60","14691.60","1 through 10","4320.43","50741.82","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","15679.48","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12798.35","","Fee schedule rate ($12,798.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16461.24","16461.24","16461.24","1 through 10","4320.43","50741.82","case rate",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","AETNA [1001]","HB CH AETNA HMO / PPO","5054.61","58.3","","1530.90","1160.93","1884.08","89","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4595.10","53","","5253.92","5253.92","5253.92","1 through 10","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5028.60","58","","12181.47","12181.47","12181.47","1 through 10","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5418.75","62.5","","1350.68","1350.68","1350.68","1 through 10","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3853.82","44.45","","1910.74","891.94","1910.74","1 through 10","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","WELLPOINT [1015]","HB CH WELLPOINT","6754.80","77.91","","1829.79","1561.50","2617.12","88","3853.82","6754.8","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5141.31","59.3","","1359.46","1201.30","1689.00","61","4335","6801.62","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5141.31","59.3","","1718.92","1718.92","1718.92","1 through 10","4335","6801.62","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6801.62","78.45","","1910.74","1019.06","2344.84","74","4335","6801.62","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","52","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.09","167.47","182.49","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","185.10","182.09","185.81","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1558.00","1168.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","923.89","59.3","","887.79","887.79","1478.05","1 through 10","224.5","1222.25","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1558.00","1168.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1222.25","78.45","","1164.73","690.23","1164.73","1 through 10","224.5","1222.25","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1999.00","1499.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1459.27","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1999.00","1499.25","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","557.43","50","176.52","1459.27","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1999.00","1499.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.09","167.07","182.69","1 through 10","176.52","1459.27","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1999.00","1499.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","185.10","182.09","185.81","1 through 10","176.52","1459.27","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1999.00","1499.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1185.41","59.3","","1139.18","1139.18","1139.18","1 through 10","224.5","1568.22","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1999.00","1499.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1568.22","78.45","","1494.55","1494.55","1494.55","1 through 10","224.5","1568.22","percent of total billed charges",""
"Doppler Velocity Ductus Venosus","PX-40000172","CDM","76999","CPT","0402","RC","","","","both","","","563.00","422.25","AETNA [1001]","HB CH AETNA HMO / PPO","328.23","58.3","","310.15","310.15","310.15","1 through 10","99.34","535.41","percent of total billed charges",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","143368.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","112810.68","","Standard inlier is a Case rate ($112,810.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $127,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,013.92) for the length of stay and the standard reimbursement.","112810.67","112810.67","112810.67","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","143368.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","121181.17","","Standard inlier is a Case rate ($121,181.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $127,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,201.15) for the length of stay and the standard reimbursement.","121181.16","115672.93","121181.16","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","143368.96","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","54283.2696","","Fee schedule rate ($92,913.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54283.2696","92913.24","92913.24","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","143368.96","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","47014.16","","Fee schedule rate ($47,014.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47013.81","47013.81","47013.81","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","143368.96","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","117891.36","","Fee schedule rate ($117,891.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","114458.69","114458.69","114458.69","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","84196.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","67323.09","","Standard inlier is a Case rate ($67,323.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,556.78) for the length of stay and the standard reimbursement.","67323.09","67323.09","67323.09","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","84196.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","72318.43","","Standard inlier is a Case rate ($72,318.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,265.30) for the length of stay and the standard reimbursement.","72318.43","69031.22","72318.43","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","84196.46","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","54283.2696","","Fee schedule rate ($64,631.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54283.2696","56433.16","56433.16","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","84196.46","","MASSHEALTH [3001]","HB NWH MEDICAID","28137.62","","Case rate ($30,313.84). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $72,743.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30391.80","30391.80","30391.80","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","84196.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","78402.45","","Fee schedule rate ($78,402.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68805.36","68805.36","68805.36","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","67323.09","","Standard inlier is a Case rate ($67,323.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,556.78) for the length of stay and the standard reimbursement.","80971.42","80971.42","80971.42","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","72318.43","","Standard inlier is a Case rate ($72,318.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,265.30) for the length of stay and the standard reimbursement.","85912.04","82012.28","85912.04","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","54283.2696","","Fee schedule rate ($64,631.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54283.2696","64631.40","64631.40","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","56997.9144","","Fee schedule rate ($67,863.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","56997.9144","70553.18","70553.18","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","71095.68","","Fee schedule rate ($71,095.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71095.68","71095.68","71095.68","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","MASSHEALTH [3001]","HB NWH MEDICAID","28137.62","","Case rate ($30,313.84). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $72,743.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24969.45","24969.45","24969.45","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","100321.26","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","36783.60","","Fee schedule rate ($36,783.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54057.73","54057.73","54057.73","1 through 10","28137.62","289505.26","case rate",""
"Dorsal And Lumbar Fusion Procedure For Curvature Of Back,MAJOR","303","DRG","","","","","","","","inpatient","","","169323.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","164669.71","","Standard inlier is a Case rate ($164,669.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $180,580, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($23,375.51) for the length of stay and the standard reimbursement.","157186.85","157186.85","157186.85","1 through 10","42673.08","223051.09","case rate",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","AETNA [1001]","HB CH AETNA HMO / PPO","969.05","58.3","","2190.90","412.50","9264.59","16","738.84","1295","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","964.06","58","","1903.20","1903.20","3826.66","1 through 10","738.84","1295","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1038.86","62.5","","2186.25","2186.25","2186.25","32","738.84","1295","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1213.39","73","","5556.60","5556.60","5556.60","1 through 10","738.84","1295","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","WELLPOINT [1015]","HB CH WELLPOINT","1295.00","77.91","","1955.15","885.83","3150.40","26","738.84","1295","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.18","1246.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","985.67","59.3","","831.03","253.22","2394.88","18","831.09","1303.98","percent of total billed charges",""
"DOWEL CANCELLOUS 12MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010248","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.18","1246.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1303.98","78.45","","2481.69","1563.74","8149.28","1 through 10","831.09","1303.98","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","both","","","3614.64","2710.98","AETNA [1001]","HB CH AETNA HMO / PPO","2107.34","58.3","","2190.90","412.50","9264.59","16","1606.71","2816.17","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","both","","","3614.64","2710.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2096.49","58","","1903.20","1903.20","3826.66","1 through 10","1606.71","2816.17","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","both","","","3614.64","2710.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2259.15","62.5","","2186.25","2186.25","2186.25","32","1606.71","2816.17","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","both","","","3614.64","2710.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2638.69","73","","5556.60","5556.60","5556.60","1 through 10","1606.71","2816.17","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","both","","","3614.64","2710.98","WELLPOINT [1015]","HB CH WELLPOINT","2816.17","77.91","","1955.15","885.83","3150.40","26","1606.71","2816.17","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3614.64","2710.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2143.48","59.3","","831.03","253.22","2394.88","18","1807.32","2835.69","percent of total billed charges",""
"DOWEL CANNULATED 13MM REVISION","SUP-ITM-10306153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3614.64","2710.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2835.69","78.45","","2481.69","1563.74","8149.28","1 through 10","1807.32","2835.69","percent of total billed charges",""
"Dpyd Gene Analysis Common Variants","PX-31000896","CDM","81232","CPT","0310","RC","","","","both","","","1460.00","1095.00","AETNA [1001]","HB CH AETNA HMO / PPO","851.18","58.3","","805.14","805.14","805.14","1 through 10","171.31","1387","percent of total billed charges",""
"Dpyd Gene Analysis Common Variants","PX-31000896","CDM","81232","CPT","0310","RC","","","","outpatient","","","1460.00","1095.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","865.78","59.3","","832.12","832.12","832.12","1 through 10","430.62","1145.37","percent of total billed charges",""
"Drain Absc/Cyst Vestib Mouth Smp","PX-75000006","CDM","40800","CPT","0761","RC","","","","outpatient","","","639.00","479.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","313.56","49.07","","468.40","468.40","468.40","1 through 10","255.6","501.3","percent of total billed charges",""
"Drain Abscess Scrotal Wall","PX-76001319","CDM","55100","CPT","0761","RC","","","","outpatient","","","2835.00","2126.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1681.16","59.3","","7538.30","7538.30","7538.30","1 through 10","1134","2224.06","percent of total billed charges",""
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","outpatient","","","496.00","372.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","285.72","285.72","285.72","1 through 10","176.45","567.68","other","ASC "
"DRILL SPINE STRAIGHT","SUP-ITM-10155784","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","5530.54","5530.54","5530.54","1 through 10","165","258.89","percent of total billed charges",""
"Drug Admin & Hemodynamic Measure","PX-48000128","CDM","93463","CPT","0481","RC","","","","both","","","3025.00","2268.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1603.25","53","","1558.73","1558.73","1558.73","1 through 10","1603.25","2356.78","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","1 through 10","18.27","113.17","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","89.66","67.98","154.81","1 through 10","28.89","93.36","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","89.18","89.18","89.18","1 through 10","28.89","93.36","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","230.00","172.50","WELLPOINT [1015]","HB CH WELLPOINT","179.19","77.91","","176.42","176.42","176.42","1 through 10","37.8","218.5","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","230.00","172.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","115.23","50.1","","142.02","115.45","142.02","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","131.26","131.26","131.26","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","102.05","102.05","102.05","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Felbamate","PX-30003722","CDM","80167","CPT","0301","RC","","","","both","","","155.00","116.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","98.27","63.4","","100.11","96.34","100.11","1 through 10","18.27","147.41","percent of total billed charges",""
"Drug Assay Felbamate","PX-30003722","CDM","80167","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","28.89","121.6","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","127.01","127.01","127.01","1 through 10","37.8","218.5","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","230.00","172.50","WELLPOINT [1015]","HB CH WELLPOINT","179.19","77.91","","176.42","176.42","176.42","1 through 10","37.8","218.5","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","230.00","172.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","115.23","50.1","","142.02","115.45","145.95","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","131.26","131.26","131.26","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","164.55","102.05","164.55","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","134.00","100.50","AETNA [1001]","HB CH AETNA HMO / PPO","78.12","58.3","","73.71","73.71","73.71","1 through 10","26.57","143.95","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","134.00","100.50","WELLPOINT [1015]","HB CH WELLPOINT","104.40","77.91","","102.39","102.39","102.39","1 through 10","26.57","143.95","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","67.13","50.1","","67.01","67.01","82.42","1 through 10","49.04","105.12","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.12","78.45","","99.94","59.23","99.94","1 through 10","49.04","105.12","percent of total billed charges",""
"Drug Assay Posaconazole","PX-30003608","CDM","80187","CPT","0300","RC","","","","outpatient","","","225.00","168.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","112.73","50.1","","138.85","138.85","138.85","1 through 10","82.35","176.51","percent of total billed charges",""
"Drug Assay Posaconazole","PX-30003608","CDM","80187","CPT","0300","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","168.37","168.37","168.37","12","82.35","176.51","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","1 through 10","18.27","112.22","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","76.81","67.37","112.89","1 through 10","28.89","92.57","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","88.41","88.41","1 through 10","28.89","92.57","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","outpatient","","","226.00","169.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","113.23","50.1","","139.48","139.48","139.48","1 through 10","82.72","177.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","1 through 10","12.99","143.45","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","151.00","113.25","WELLPOINT [1015]","HB CH WELLPOINT","117.64","77.91","","115.78","115.78","115.78","1 through 10","12.99","143.45","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","1 through 10","13.67","118.46","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","66.97","113.01","1 through 10","13.67","118.46","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","both","","","151.00","113.25","WELLPOINT [1015]","HB CH WELLPOINT","117.64","77.91","","115.78","115.78","115.78","1 through 10","19.75","143.45","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","11","19.07","118.46","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","113.01","113.01","1 through 10","19.07","118.46","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Free","PX-30002831","CDM","80165","CPT","0301","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","13.27","114.95","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","89.59","89.59","89.59","1 through 10","13.27","153.9","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","92.59","91.34","92.59","1 through 10","13.98","127.09","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","121.47","45.68","121.47","1 through 10","13.98","127.09","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","1 through 10","12.99","100.7","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","106.00","79.50","WELLPOINT [1015]","HB CH WELLPOINT","82.58","77.91","","81.12","81.12","81.12","1 through 10","12.99","100.7","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","1 through 10","13.67","83.16","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","both","","","137.00","102.75","AETNA [1001]","HB CH AETNA HMO / PPO","79.87","58.3","","75.41","75.41","75.41","1 through 10","13.01","130.15","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","outpatient","","","137.00","102.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.24","59.3","","77.94","77.94","77.94","1 through 10","13.69","107.48","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","12.99","105.45","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.78","82.78","82.78","1 through 10","12.99","142.5","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","112.25","112.25","112.25","1 through 10","12.99","142.5","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","114.99","114.99","114.99","1 through 10","12.99","142.5","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","85.56","85.56","239.68","1 through 10","13.67","117.68","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","112.25","66.52","112.25","1 through 10","13.67","117.68","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","12.99","105.45","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Dstrj Lesion Anus Smpl Eltrdsiccation","PX-75000233","CDM","46910","CPT","0750","RC","","","","outpatient","","","5356.00","4017.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2628.19","49.07","","2504.65","2504.65","2504.65","1 through 10","2142.4","4201.78","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","AETNA [1001]","HB CH AETNA HMO / PPO","1809.63","58.3","","1711.21","1711.21","1711.21","1 through 10","272.7","2265.92","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","FALLON HEALTH [1008]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.62","284.62","284.62","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","HUMANA [1012]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","45","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2265.92","73","","1711.21","1711.21","1711.21","1 through 10","272.7","2265.92","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","TRICARE [160005]","HB NWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","2265.92","other","Tricare OPPS"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.72","281.32","843.96","12","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1379.73","44.45","","2320.24","1375.00","2320.24","1 through 10","272.7","2265.92","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","262.60","282.47","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3104.00","2328.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1840.67","59.3","","1768.55","1768.53","1768.55","25","380.73","2435.09","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3104.00","2328.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2435.09","78.45","","2320.24","1375.00","2320.24","18","380.73","2435.09","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","AETNA [1001]","HB CH AETNA HMO / PPO","988.19","58.3","","1711.21","1711.21","1711.21","1 through 10","119.97","1237.35","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","13","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1237.35","73","","1203.04","934.42","1203.04","1 through 10","119.97","1237.35","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1237.35","other","Tricare OPPS"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.43","44.45","","1266.99","1266.99","1266.99","1 through 10","119.97","1237.35","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","119.99","126.29","1 through 10","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1695.00","1271.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.14","59.3","","2897.19","965.73","2897.19","1 through 10","185.79","1329.73","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","1266.98","1266.98","1266.99","1 through 10","185.79","1329.73","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","AETNA [1001]","HB CH AETNA HMO / PPO","1207.39","58.3","","1141.94","1141.94","1141.94","1 through 10","272.7","1511.83","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1511.83","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","44","272.7","1511.83","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","281.32","281.92","1 through 10","272.7","1511.83","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","267.10","286.32","1 through 10","272.7","1511.83","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","2071.00","1553.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1228.10","59.3","","1180.20","1180.20","1180.20","1 through 10","380.73","1624.7","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","2071.00","1553.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1624.70","78.45","","1548.36","917.58","1548.36","1 through 10","380.73","1624.7","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Ltd","PX-92000045","CDM","93979","CPT","0921","RC","","","","both","","","1481.00","1110.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1081.13","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Ltd","PX-92000045","CDM","93979","CPT","0921","RC","","","","both","","","1481.00","1110.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","117.99","124.16","1 through 10","119.97","1081.13","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Ltd","PX-92000045","CDM","93979","CPT","0921","RC","","","","outpatient","","","1481.00","1110.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","878.23","59.3","","843.84","843.84","843.84","1 through 10","185.79","1161.84","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2663.00","1997.25","AETNA [1001]","HB CH AETNA HMO / PPO","1552.53","58.3","","1467.96","1467.96","1467.96","1 through 10","272.7","1943.99","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2663.00","1997.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","1943.99","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2663.00","1997.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","1943.99","other","OPPS APC"
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","both","","","1713.00","1284.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.77","126.29","1 through 10","119.97","1250.49","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","25","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","289","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","MOLINA [1014]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","569.53","569.53","569.53","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","TRICARE [160005]","HB NWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","1533","other","Tricare OPPS"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","262.49","845.16","30","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.92","281.32","286.32","26","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1196.61","1196.61","1196.61","15","380.73","1647.45","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1569.89","930.34","1569.89","15","380.73","1647.45","percent of total billed charges",""
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1415.00","1061.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1032.95","other","OPPS APC"
"Duplex Hemodialysis Access","PX-92000049","CDM","93990","CPT","0921","RC","","","","both","","","1726.00","1294.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1259.98","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","FALLON HEALTH [1008]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","267.44","267.44","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","114","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","1508.91","other","Tricare OPPS"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.72","281.32","843.96","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","281.32","286.32","20","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2067.00","1550.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1225.73","59.3","","1177.86","1177.86","1177.87","1 through 10","380.73","1621.56","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1621.56","78.45","","1545.28","915.76","1545.29","11","380.73","1621.56","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1380.00","1035.00","AETNA [1001]","HB CH AETNA HMO / PPO","804.54","58.3","","979.66","979.66","979.66","1 through 10","119.97","1007.4","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1380.00","1035.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","1007.4","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1380.00","1035.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1007.40","73","","1140.70","1140.70","1140.70","1 through 10","119.97","1007.4","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","29","119.97","1007.4","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3596.00","2697.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1801.60","50.1","","248.00","248.00","248.00","1 through 10","1542.68","2821.06","percent of total billed charges",""
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","25609.78","19207.33","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6707.16","","Case rate ($6,511.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,689.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,831.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,439.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,014.18. The transfer operating threshold is the transfer adjustment factor * $6,689.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.63. The transfer capital threshold is the transfer adjustment factor * $497.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6695.77","6695.77","6695.77","1 through 10","6381.57","7392.0275","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","25609.78","19207.33","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7159.90","","Case rate ($7,159.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,689.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,831.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,439.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,662.27. The transfer operating threshold is the transfer adjustment factor * $6,689.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.63. The transfer capital threshold is the transfer adjustment factor * $497.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7032.75","7032.75","7032.75","1 through 10","6381.57","7392.0275","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","25609.78","19207.33","MEDICARE [2001]","HB NWH MEDICARE","7159.90","","Case rate ($7,159.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,689.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,831.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,439.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,662.27. The transfer operating threshold is the transfer adjustment factor * $6,689.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.63. The transfer capital threshold is the transfer adjustment factor * $497.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7134.28","1194.03","7147.10","26","6381.57","7392.0275","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","25609.78","19207.33","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6381.57","","Case rate ($6,511.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,689.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,831.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,439.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,014.18. The transfer operating threshold is the transfer adjustment factor * $6,689.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.63. The transfer capital threshold is the transfer adjustment factor * $497.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6389.57","6377.65","6394.57","1 through 10","6381.57","7392.0275","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","25609.78","19207.33","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6381.57","","Case rate ($6,511.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,689.40, add-ons for qualifying new technology services are included. If operating cost exceeds $51,831.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,439.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,014.18. The transfer operating threshold is the transfer adjustment factor * $6,689.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.63. The transfer capital threshold is the transfer adjustment factor * $497.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6408.65","6408.65","6408.65","1 through 10","6381.57","7392.0275","other","Inpatient DRG"
"E&C Hydatidform Mole (Eap 59870)","PX-72000037","CDM","59870","CPT","0361","RC","","","","both","","","8940.00","6705.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","6965.15","other","Multiple Surgery"
"EAR IMPLANT 4.2MM 1.4MM CANNULATION STAPES GOLBERG UNCUS PRO","SUP-ITM-10287206","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1070.10","802.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","634.57","59.3","","782.24","782.24","782.24","1 through 10","535.05","839.49","percent of total billed charges",""
"EAR IMPLANT 8.2MM .8MM SHAFT STAPES GOLBERG UNCUS PRO","SUP-ITM-10287207","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1072.35","804.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","635.90","59.3","","782.24","782.24","782.24","1 through 10","536.18","841.26","percent of total billed charges",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","","","","inpatient","","","58696.23","44022.17","MEDICARE [2001]","HB NWH MEDICARE","12112.57","","Case rate ($12,112.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,316.61, add-ons for qualifying new technology services are included. If operating cost exceeds $56,458.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,783.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,270.72. The transfer operating threshold is the transfer adjustment factor * $11,316.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.85. The transfer capital threshold is the transfer adjustment factor * $841.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11901.95","11901.95","11901.95","1 through 10","10795.87","12309.8272","other","Inpatient DRG"
"Ear, Nose, Mouth And Throat Malignancy With McC","146","MS-DRG","","","","","","","","inpatient","","","15666.02","11749.51","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","18345.00","","Case rate ($18,345). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,845.29, add-ons for qualifying new technology services are included. If operating cost exceeds $63,987.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,343.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $16,943.09. The transfer operating threshold is the transfer adjustment factor * $18,845.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,401.91. The transfer capital threshold is the transfer adjustment factor * $1,401.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19789.05","19789.05","19789.05","1 through 10","17978.1","21735.11","other","Inpatient Replacement Plans DRG"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","460.00","345.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.16","41.16","41.16","1 through 10","42.07","335.8","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","460.00","345.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","272.78","59.3","","261.94","261.94","261.94","1 through 10","61.36","374.98","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","460.00","345.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","360.87","78.45","","305.76","305.76","305.76","1 through 10","61.36","374.98","percent of total billed charges",""
"Ecg Monitor/Report Up to 48 Hrs Rec","PX-73000007","CDM","93225","CPT","0731","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.64","150.52","150.64","1 through 10","145.42","669.41","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","966.29","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","966.35","965.45","969.39","12","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","923.23","923.23","19","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","ELDER SERVICES [1037]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","856.40","856.40","856.40","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","HUMANA [1012]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","921.28","919.48","925.10","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","MEDICARE [2001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","299","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","MOLINA [1014]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1862.06","1862.06","1862.06","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.88","919.48","1714.00","52","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.88","857.21","920.48","37","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","2401.00","1800.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1883.58","78.45","","1795.15","1063.83","1795.15","17","821.51","1996.77","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","364.01","364.01","364.01","1 through 10","293.37","481.8","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","382.80","58","","62.82","62.82","62.82","1 through 10","293.37","481.8","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","382.80","58","","73.90","71.76","73.90","1 through 10","293.37","481.8","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","412.50","62.5","","81.44","81.44","81.44","1 through 10","293.37","481.8","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","376.21","376.21","460.47","11","330","517.77","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","493.57","292.50","493.57","13","330","517.77","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","377.58","58","","117.31","117.31","120.81","1 through 10","289.37","475.23","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","406.88","62.5","","133.13","133.13","133.13","1 through 10","289.37","475.23","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","651.00","488.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.04","59.3","","370.94","370.94","370.94","1 through 10","325.5","510.71","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.71","78.45","","486.65","288.39","486.65","1 through 10","325.5","510.71","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","AETNA [1001]","HB CH AETNA HMO / PPO","219.79","58.3","","208.09","208.09","208.09","1 through 10","167.58","316.25","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","218.66","58","","55.61","55.61","55.61","1 through 10","167.58","316.25","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","218.66","58","","65.42","65.42","65.42","1 through 10","167.58","316.25","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","235.63","62.5","","72.09","72.09","72.09","1 through 10","167.58","316.25","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","377.00","282.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.56","59.3","","215.06","183.09","263.23","1 through 10","188.5","295.76","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","282.15","167.21","282.15","1 through 10","188.5","295.76","percent of total billed charges",""
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","966.29","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2220.00","899.22","2220.00","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","859.90","923.23","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","MEDICARE [2001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","873.88","938.24","47","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.88","856.80","923.23","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","938.24","938.24","938.24","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.98","919.98","919.98","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","outpatient","","","2283.00","1712.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1791.01","78.45","","1706.74","1011.43","1706.74","1 through 10","821.51","1996.77","percent of total billed charges",""
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","3065.00","2298.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","966.29","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","965.45","965.45","965.45","1 through 10","891.33","2690.91","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","3065.00","2298.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","923.23","923.23","1 through 10","891.33","2690.91","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","3065.00","2298.75","MEDICARE [2001]","HB NWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","1 through 10","891.33","2690.91","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","3065.00","2298.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.48","919.48","919.48","1 through 10","891.33","2690.91","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","2767.00","2075.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","592.48","592.48","592.48","1 through 10","618.58","2019.91","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","2767.00","2075.25","MEDICARE [2001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","651.14","53","618.58","2019.91","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","2767.00","2075.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.52","638.12","638.52","1 through 10","618.58","2019.91","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","2767.00","2075.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","639.12","638.62","640.73","1 through 10","618.58","2019.91","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","2767.00","2075.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1640.83","59.3","","1576.93","1539.25","1576.93","1 through 10","821.51","2846.52","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","2767.00","2075.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2170.71","78.45","","2068.84","1226.02","2068.84","1 through 10","821.51","2846.52","percent of total billed charges",""
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","436.79","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","437.31","437.31","438.19","1 through 10","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","1272.33","29","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.23","416.03","416.23","1 through 10","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","415.63","1 through 10","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","outpatient","","","1090.00","817.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","855.11","78.45","","814.93","814.93","814.93","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","AETNA [1001]","HB CH AETNA HMO / PPO","574.26","58.3","","543.19","543.19","543.19","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","130.25","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","HUMANA [1012]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.55","281.55","281.55","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","49","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","267.10","286.32","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.11","59.3","","4445.99","561.39","4445.99","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","772.73","78.45","","736.51","436.46","736.51","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","AETNA [1001]","HB CH AETNA HMO / PPO","574.26","58.3","","543.19","543.19","543.19","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","130.25","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","HUMANA [1012]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.55","281.55","281.55","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","49","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","267.10","286.32","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.11","59.3","","4445.99","561.39","4445.99","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","772.73","78.45","","736.51","436.46","736.51","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","AETNA [1001]","HB CH AETNA HMO / PPO","1001.01","58.3","","1893.78","946.89","1893.78","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","MEDICARE [2001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","651.14","93","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.52","638.12","1914.36","11","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","639.12","591.28","643.12","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1018.18","59.3","","1300.92","978.62","1300.92","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.21","44.45","","1283.90","1283.90","1283.90","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1346.99","78.45","","1283.90","1283.90","1283.90","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","AETNA [1001]","HB CH AETNA HMO / PPO","1432.43","58.3","","1354.56","1323.95","2647.90","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","84","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","FALLON HEALTH [1008]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","602.11","602.11","602.11","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","HUMANA [1012]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.64","590.55","638.64","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","MEDICARE [2001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","651.14","1027","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","TRICARE [160005]","HB NWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","651.14","651.14","651.14","1 through 10","618.58","1935.24","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.52","638.12","1914.36","143","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","651.14","651.14","651.14","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1092.14","44.45","","1836.66","1836.66","1836.66","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","640.73","638.12","643.12","77","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1092.14","44.45","","1088.43","1088.43","1088.43","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","2457.00","1842.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1457.00","59.3","","1399.95","1368.31","2304.73","107","821.51","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","2457.00","1842.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1927.52","78.45","","1836.66","1088.43","1836.66","83","821.51","1996.77","percent of total billed charges",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","320356.84","240267.63","MEDICARE [2001]","HB NWH MEDICARE","202195.57","","Case rate ($202,195.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $188,908.63, add-ons for qualifying new technology services are included. If operating cost exceeds $234,050.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $16,994.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $188,142.60. The transfer operating threshold is the transfer adjustment factor * $188,908.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $14,052.96. The transfer capital threshold is the transfer adjustment factor * $14,052.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","204914.58","204914.58","204914.58","1 through 10","180215.7","217876.68","other","Inpatient DRG"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1385.00","1038.75","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1011.05","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","AETNA [1001]","HB CH AETNA HMO / PPO","887.33","58.3","","839.16","839.16","839.16","1 through 10","176.52","1185.79","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","1678.00","1258.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","16","351.32","1224.94","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","1678.00","1258.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.92","362.92","1 through 10","351.32","1224.94","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","1678.00","1258.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","995.05","59.3","","956.35","956.35","956.35","1 through 10","416.64","1316.39","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","1678.00","1258.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1316.39","78.45","","1254.68","1254.68","1254.68","1 through 10","416.64","1316.39","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","AETNA [1001]","HB CH AETNA HMO / PPO","868.67","58.3","","821.58","821.58","821.58","1 through 10","351.32","1087.7","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","48","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","TRICARE [160005]","HB NWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","351.32","351.32","351.32","1 through 10","351.32","1087.7","other","Tricare OPPS"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.41","362.81","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.42","369.81","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1490.00","1117.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","883.57","59.3","","849.11","849.11","986.75","1 through 10","416.64","1168.91","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1490.00","1117.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1168.91","78.45","","1113.99","660.16","1113.99","1 through 10","416.64","1168.91","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2253.00","1689.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4445.82","2043.55","4445.82","1 through 10","1194.09","2320.14","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","2252.79","4518.11","1 through 10","1194.09","2320.14","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2253.00","1689.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2215.64","2215.64","1 through 10","1194.09","2320.14","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3177.35","3177.35","3177.35","1 through 10","1001.46","1873.9","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","AETNA [1001]","HB CH AETNA HMO / PPO","1228.96","58.3","","1162.35","1162.35","1162.35","1 through 10","761.55","1538.84","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","572.85","1154.60","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","547.79","1095.60","11","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1331.67","1255.12","1972.41","1 through 10","761.55","1538.84","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","HUMANA [1012]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","86","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","3145.00","1702.00","3145.00","1 through 10","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1788.00","1788.00","1 through 10","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","19","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3277.92","1093.14","3277.92","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1093.15","545.58","1099.05","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.01","44.45","","933.98","933.98","933.98","1 through 10","761.55","1538.84","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","615.71","1257.55","29","761.55","1873.9","other","ASC "
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","616.59","1259.29","47","761.55","1873.9","other","ASC "
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1250.04","59.3","","1201.30","1200.83","3095.84","1 through 10","761.55","1873.9","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","894.82","1789.64","28","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1881.03","940.52","1972.41","1 through 10","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1653.73","78.45","","1576.04","933.98","1811.86","1 through 10","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","AETNA [1001]","HB CH AETNA HMO / PPO","1310.58","58.3","","1239.46","1239.46","1239.46","66","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","572.85","1152.70","32","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","547.79","1095.60","44","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","FALLON HEALTH [1008]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2238.96","1119.48","2238.96","1 through 10","761.55","1641.04","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","986.21","3944.82","35","761.55","1641.04","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1310.58","58.3","","1239.46","1239.46","1239.46","1 through 10","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","3340.23","531","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","4340.10","13","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","5106.00","50","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1685.00","1788.00","1 through 10","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","118","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MOLINA [1014]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2209.01","1102.29","2209.01","1 through 10","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1094.14","547.58","3279.42","62","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","999.24","44.45","","995.94","995.94","995.94","1 through 10","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","545.58","1099.05","56","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","1972.41","1972.41","1 through 10","761.55","1641.04","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","628.78","1257.55","162","761.55","1873.9","other","ASC "
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","616.59","1259.29","399","761.55","1873.9","other","ASC "
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1333.06","59.3","","2500.79","1281.00","3843.40","150","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","894.82","5368.92","194","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2238.96","940.52","5643.09","71","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1812.49","1812.49","1812.49","1 through 10","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1763.56","78.45","","1680.60","995.94","1680.60","51","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2327.02","2327.02","2327.02","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2215.64","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3095.00","2321.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","2428.03","other","ASC "
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3095.00","2321.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","2428.03","other","Multiple Surgery"
"Egd Flex Transoral W/Ins Tube/Cath","PX-75000093","CDM","43241","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","966.54","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3130.00","2347.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1822.00","1822.00","1822.00","1 through 10","1335.02","2906.42","per diem",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3130.00","2347.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2398.57","1 through 10","1335.02","2455.49","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3130.00","2347.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2401.96","1 through 10","1335.02","2455.49","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.22","2325.22","2325.22","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","4445.82","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","6758.37","16","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.13","2215.13","2215.13","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2398.57","1 through 10","1335.02","4472.66","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2401.96","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","AETNA [1001]","HB CH AETNA HMO / PPO","1502.39","58.3","","1420.90","1420.90","1420.90","1 through 10","1145.48","2906.42","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2144.91","2318.12","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2043.55","2216.75","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","76","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1145.48","2906.42","per diem",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","5631.00","1 through 10","1145.48","2906.42","per diem",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.23","2042.64","2215.53","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2042.25","2216.75","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2398.57","2449.46","18","1288.5","2021.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1288.5","2021.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2452.85","32","1288.5","2021.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1528.16","59.3","","1468.52","1433.43","1468.52","1 through 10","1288.5","2021.66","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3017.15","3137.30","18","1288.5","2021.66","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3297.50","3297.50","3924.96","1 through 10","1288.5","2021.66","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3177.35","3177.35","3177.35","1 through 10","1288.5","2021.66","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2021.66","78.45","","1926.61","1926.61","1926.61","1 through 10","1288.5","2021.66","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3406.00","2554.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3406.00","2554.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1200.98","1200.98","1200.98","1 through 10","1335.02","4472.66","other","ASC "
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2077.00","1557.75","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","761.55","1516.21","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2077.00","1557.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","761.55","1516.21","per diem",""
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2077.00","1557.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.15","976.58","1091.15","1 through 10","761.55","1516.21","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","outpatient","","","2077.00","1557.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1259.29","1259.29","1 through 10","761.55","1873.9","other","ASC "
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2229.00","1671.75","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","761.55","1627.17","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2229.00","1671.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","1091.14","1091.14","1 through 10","761.55","1627.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3346.00","2509.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2606.87","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3346.00","2509.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","38","1335.02","2606.87","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3346.00","2509.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","1 through 10","1335.02","2606.87","per diem",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3346.00","2509.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.74","2039.40","2216.75","1 through 10","1335.02","2606.87","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3346.00","2509.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2449.46","2449.46","1 through 10","1335.02","7178","other","ASC "
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","3465.00","2598.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1700.28","49.07","","1257.55","1257.55","1257.55","1 through 10","1700.28","7178","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","AETNA [1001]","HB CH AETNA HMO / PPO","1869.10","58.3","","1767.34","1767.34","1767.34","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.73","2207.73","2207.73","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3179.00","2384.25","AETNA [1001]","HB CH AETNA HMO / PPO","1853.36","58.3","","3505.20","3505.20","3505.20","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3179.00","2384.25","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3179.00","2384.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2215.64","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2401.96","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","494.68","1670.10","26","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","761.55","1644.69","per diem",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","545.58","1098.54","1 through 10","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.65","1095.60","1098.65","1 through 10","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","615.71","1257.55","1 through 10","761.55","4472.66","other","ASC "
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","616.59","1259.29","1 through 10","761.55","4472.66","other","ASC "
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","1789.64","1789.64","1 through 10","761.55","4472.66","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","906.25","906.25","906.25","1 through 10","761.55","4472.66","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1767.48","78.45","","998.22","998.22","2719.93","1 through 10","761.55","4472.66","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3159.00","2369.25","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3159.00","2369.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.13","2215.13","2215.13","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3159.00","2369.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","AETNA [1001]","HB CH AETNA HMO / PPO","1971.71","58.3","","1864.86","1864.86","1864.86","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.12","2325.12","2325.12","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","17","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.73","2043.15","2207.73","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2398.57","2449.46","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","1226.43","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2005.53","59.3","","1927.35","1927.35","1927.35","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2653.18","78.45","","2528.58","2528.58","2528.58","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","AETNA [1001]","HB CH AETNA HMO / PPO","1824.21","58.3","","1725.38","1725.38","1725.38","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","6758.37","16","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.13","2209.23","2215.13","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2215.64","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2398.57","2449.46","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3297.50","3297.50","3297.50","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","88.45","88.45","88.45","1 through 10","9.98","76","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","45.71","1 through 10","10.07","62.76","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","36.76","36.76","36.76","1 through 10","10.07","62.76","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","44.45","","73.56","73.56","73.56","1 through 10","11.74","97.85","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","1 through 10","13.54","76","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","137.13","11","11.81","72.16","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","35.54","59.97","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","72.00","54.00","AETNA [1001]","HB CH AETNA HMO / PPO","41.98","58.3","","39.69","39.69","39.69","1 through 10","11.74","70.73","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","72.00","54.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.70","59.3","","41.02","41.02","123.06","20","11.81","72.16","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.48","78.45","","53.82","31.89","53.82","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","32","14.09","129.2","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","136.00","102.00","TRICARE [160005]","HB NWH TRICARE","129.20","95","","17.33","17.33","17.33","1 through 10","14.09","129.2","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.45","44.45","","101.48","101.48","101.48","1 through 10","14.09","129.2","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","33","11.84","106.69","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","60.14","101.48","26","11.84","106.69","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","AETNA [1001]","HB CH AETNA HMO / PPO","50.14","58.3","","47.63","47.63","47.63","369","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","62.78","73","","61.32","61.32","61.32","1 through 10","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","62.78","73","","84.00","47.63","84.00","1 through 10","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB NWH TRICARE","81.70","95","","11.83","11.83","12.45","1 through 10","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.23","44.45","","64.58","38.27","64.58","15","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.23","44.45","","64.58","64.58","64.58","1 through 10","10.12","81.7","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","86.00","64.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","51.00","59.3","","49.22","49.22","49.22","333","10.66","67.47","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","67.47","78.45","","64.58","38.27","64.58","297","10.66","67.47","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","11.3","91.2","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","11","11.9","75.31","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","37.07","71.50","1 through 10","11.9","75.31","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","147.42","147.42","147.42","446","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","189.80","189.80","189.80","1 through 10","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","166.70","166.70","166.70","1 through 10","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","TRICARE [160005]","HB NWH TRICARE","253.65","95","","29.02","27.57","29.02","1 through 10","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","199.89","118.46","199.89","13","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","199.89","199.89","199.89","1 through 10","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","267.00","200.25","WELLPOINT [1015]","HB CH WELLPOINT","208.02","77.91","","204.78","204.78","464.78","78","23.6","253.65","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","267.00","200.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.33","59.3","","152.36","152.36","152.36","362","23.19","209.46","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","199.89","118.46","199.89","333","23.19","209.46","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","123.60","1 through 10","11.74","106.4","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","99.34","99.34","99.34","1 through 10","11.74","106.4","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.88","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","123.60","1 through 10","11.74","106.4","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","99.34","99.34","99.34","1 through 10","11.74","106.4","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.88","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","107.74","32","11.74","93.1","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","both","","","98.00","73.50","TRICARE [160005]","HB NWH TRICARE","93.10","95","","14.44","14.44","14.44","1 through 10","11.74","93.1","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.56","44.45","","69.76","43.28","69.76","1 through 10","11.74","93.1","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","35","11.81","76.88","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","73.04","73.04","1 through 10","11.81","76.88","percent of total billed charges",""
"Eia Ql Multi Shiga-Like Toxin Ag","PX-30001255","CDM","87427","CPT","0306","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.03","43.28","73.04","23","11.81","76.88","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","AETNA [1001]","HB CH AETNA HMO / PPO","130.59","58.3","","123.61","107.19","247.22","12","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","65.69","69.41","32","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","ELDER SERVICES [1037]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","65.42","65.42","65.42","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","MEDICARE [2001]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","287","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","TRICARE [160005]","HB NWH TRICARE","67.01","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","70.54","2.87","70.54","1 through 10","67.01","217.45","other","Tricare OPPS"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.39","69.53","208.59","48","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","167.60","99.32","167.60","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.63","66.23","70.13","31","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","99.32","99.32","99.32","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.44","56","","120.54","120.54","127.75","1 through 10","125.44","158.14","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.14","70.6","","167.60","36.00","167.60","1 through 10","125.44","158.14","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","114.11","467.54","159","92.3","175.73","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","99.32","218.00","99","92.3","175.73","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","121.09","63.4","","123.32","118.67","123.32","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.90","44.45","","84.74","84.74","84.74","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","WELLPOINT [1015]","HB CH WELLPOINT","148.81","77.91","","146.49","146.49","146.49","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","95.69","50.1","","95.87","95.86","117.93","17","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.26","59.3","","109.00","109.00","327.00","12","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","110.21","57.7","","112.16","112.16","214.46","16","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","115.56","60.5","","117.74","117.74","123.32","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","115.56","60.5","","954.86","954.86","954.86","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.84","78.45","","143.00","82.79","143.00","1 through 10","69.91","149.84","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","AETNA [1001]","HB CH AETNA HMO / PPO","1744.63","58.3","","1530.90","1160.93","1884.08","89","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1586.03","53","","5253.92","5253.92","5253.92","1 through 10","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1735.65","58","","12181.47","12181.47","12181.47","1 through 10","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1870.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1330.17","44.45","","1910.74","891.94","1910.74","1 through 10","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","WELLPOINT [1015]","HB CH WELLPOINT","2331.46","77.91","","1829.79","1561.50","2617.12","88","1330.17","2331.46","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2992.50","2244.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1774.55","59.3","","1359.46","1201.30","1689.00","61","1496.25","2347.62","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2992.50","2244.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1774.55","59.3","","1718.92","1718.92","1718.92","1 through 10","1496.25","2347.62","percent of total billed charges",""
"ELBOW 12X20MM EXPLOR IMPLANT 01A","SUP-ITM-10021408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2992.50","2244.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2347.62","78.45","","1910.74","1019.06","2344.84","74","1496.25","2347.62","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1530.90","1160.93","1884.08","89","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","5253.92","5253.92","5253.92","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2074.95","58","","12181.47","12181.47","12181.47","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2235.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.20","44.45","","1910.74","891.94","1910.74","1 through 10","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","1829.79","1561.50","2617.12","88","1590.2","2787.23","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1359.46","1201.30","1689.00","61","1788.75","2806.55","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1718.92","1718.92","1718.92","1 through 10","1788.75","2806.55","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","1910.74","1019.06","2344.84","74","1788.75","2806.55","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","AETNA [1001]","HB CH AETNA HMO / PPO","2132.03","58.3","","1530.90","1160.93","1884.08","89","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1938.21","53","","5253.92","5253.92","5253.92","1 through 10","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2121.06","58","","12181.47","12181.47","12181.47","1 through 10","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2285.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.54","44.45","","1910.74","891.94","1910.74","1 through 10","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","WELLPOINT [1015]","HB CH WELLPOINT","2849.17","77.91","","1829.79","1561.50","2617.12","88","1625.54","2849.17","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3657.00","2742.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.60","59.3","","1359.46","1201.30","1689.00","61","1828.5","2868.92","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3657.00","2742.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2168.60","59.3","","1718.92","1718.92","1718.92","1 through 10","1828.5","2868.92","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3657.00","2742.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.92","78.45","","1910.74","1019.06","2344.84","74","1828.5","2868.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","AETNA [1001]","HB CH AETNA HMO / PPO","7070.62","58.3","","1530.90","1160.93","1884.08","89","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6427.84","53","","5253.92","5253.92","5253.92","1 through 10","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7034.24","58","","12181.47","12181.47","12181.47","1 through 10","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7580.00","62.5","","1350.68","1350.68","1350.68","1 through 10","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5390.90","44.45","","1910.74","891.94","1910.74","1 through 10","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","WELLPOINT [1015]","HB CH WELLPOINT","9448.92","77.91","","1829.79","1561.50","2617.12","88","5390.9","9448.92","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12128.00","9096.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7191.90","59.3","","1359.46","1201.30","1689.00","61","6064","9514.42","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12128.00","9096.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7191.90","59.3","","1718.92","1718.92","1718.92","1 through 10","6064","9514.42","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12128.00","9096.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9514.42","78.45","","1910.74","1019.06","2344.84","74","6064","9514.42","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","AETNA [1001]","HB CH AETNA HMO / PPO","3290.45","58.3","","1530.90","1160.93","1884.08","89","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2991.32","53","","5253.92","5253.92","5253.92","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3273.52","58","","12181.47","12181.47","12181.47","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3527.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.76","44.45","","1910.74","891.94","1910.74","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","WELLPOINT [1015]","HB CH WELLPOINT","4397.24","77.91","","1829.79","1561.50","2617.12","88","2508.76","4397.24","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1359.46","1201.30","1689.00","61","2822","4427.72","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1718.92","1718.92","1718.92","1 through 10","2822","4427.72","percent of total billed charges",""
"ELBOW BEARING 3.0X75MM IMPLANT ULNA BRING COMPONENT DISCOVERY RT 03","SUP-ITM-10011514","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4427.72","78.45","","1910.74","1019.06","2344.84","74","2822","4427.72","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","AETNA [1001]","HB CH AETNA HMO / PPO","1494.87","58.3","","464.71","67.87","1012.10","221","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1494.87","58.3","","293.04","293.04","293.04","11","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1358.97","53","","983.89","983.89","983.89","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1487.18","58","","677.18","677.18","677.18","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1602.56","62.5","","46.58","46.58","46.58","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1871.79","73","","747.15","747.15","747.15","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1139.74","44.45","","1141.67","481.21","1141.67","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1139.74","44.45","","76.54","76.54","76.54","1 through 10","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2564.10","1923.07","WELLPOINT [1015]","HB CH WELLPOINT","1997.69","77.91","","273.64","94.28","1367.51","138","1139.74","1997.69","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2564.10","1923.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1520.51","59.3","","720.78","230.14","2010.94","427","1282.05","2011.54","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2564.10","1923.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1520.51","59.3","","344.45","344.45","344.45","1 through 10","1282.05","2011.54","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2564.10","1923.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2011.54","78.45","","1120.13","1120.13","1120.13","1 through 10","1282.05","2011.54","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2564.10","1923.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2011.54","78.45","","456.17","105.33","1284.66","242","1282.05","2011.54","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","AETNA [1001]","HB CH AETNA HMO / PPO","3408.88","58.3","","1530.90","1160.93","1884.08","89","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3098.98","53","","5253.92","5253.92","5253.92","1 through 10","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3391.34","58","","12181.47","12181.47","12181.47","1 through 10","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3654.46","62.5","","1350.68","1350.68","1350.68","1 through 10","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2599.05","44.45","","1910.74","891.94","1910.74","1 through 10","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","WELLPOINT [1015]","HB CH WELLPOINT","4555.51","77.91","","1829.79","1561.50","2617.12","88","2599.05","4555.51","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","3467.35","59.3","","1359.46","1201.30","1689.00","61","2923.57","4587.08","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3467.35","59.3","","1718.92","1718.92","1718.92","1 through 10","2923.57","4587.08","percent of total billed charges",""
"ELBOW PROSTHESIS 19MM RADIUS HEAD 6.5MM STEM 9MM HEIGHT","SUP-ITM-10307124","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4587.08","78.45","","1910.74","1019.06","2344.84","74","2923.57","4587.08","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","AETNA [1001]","HB CH AETNA HMO / PPO","3290.45","58.3","","1530.90","1160.93","1884.08","89","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2991.32","53","","5253.92","5253.92","5253.92","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3273.52","58","","12181.47","12181.47","12181.47","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3527.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.76","44.45","","1910.74","891.94","1910.74","1 through 10","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","WELLPOINT [1015]","HB CH WELLPOINT","4397.24","77.91","","1829.79","1561.50","2617.12","88","2508.76","4397.24","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1359.46","1201.30","1689.00","61","2822","4427.72","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1718.92","1718.92","1718.92","1 through 10","2822","4427.72","percent of total billed charges",""
"ELBOW STEM 3X75MM ULNAR DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4427.72","78.45","","1910.74","1019.06","2344.84","74","2822","4427.72","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","AETNA [1001]","HB CH AETNA HMO / PPO","2579.19","58.3","","1530.90","1160.93","1884.08","89","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2344.72","53","","5253.92","5253.92","5253.92","1 through 10","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2565.92","58","","12181.47","12181.47","12181.47","1 through 10","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2765.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1966.47","44.45","","1910.74","891.94","1910.74","1 through 10","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","both","","","4424.00","3318.00","WELLPOINT [1015]","HB CH WELLPOINT","3446.74","77.91","","1829.79","1561.50","2617.12","88","1966.47","3446.74","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4424.00","3318.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2623.43","59.3","","1359.46","1201.30","1689.00","61","2212","3470.63","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4424.00","3318.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2623.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2212","3470.63","percent of total billed charges",""
"ELBOW STEM 7.0X2.0MM TITANIUM FLUTED TAPERED","SUP-ITM-10045160","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4424.00","3318.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3470.63","78.45","","1910.74","1019.06","2344.84","74","2212","3470.63","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"ELBOW STEM 8X28MM RADIAL EXPLOR W/SCREW FOR A HEAD 01B","SUP-ITM-10016744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","40739.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35696.29","","Standard inlier is a Case rate ($35,696.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,067.23) for the length of stay and the standard reimbursement.","35696.29","35696.29","35696.29","1 through 10","15175.19","40707.1","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","40739.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","38344.94","","Standard inlier is a Case rate ($38,344.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,442.90) for the length of stay and the standard reimbursement.","36601.98","36601.98","36601.98","1 through 10","15175.19","40707.1","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","40739.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38344.94","","Standard inlier is a Case rate ($38,344.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,442.90) for the length of stay and the standard reimbursement.","36601.99","36601.99","36601.99","1 through 10","15175.19","40707.1","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","47023.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40707.10","","Standard inlier is a Case rate ($40,707.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $50,524, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,778.20) for the length of stay and the standard reimbursement.","38856.77","38856.77","38856.77","1 through 10","15175.19","40707.1","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","47023.94","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","16213.60","","Case rate ($17,467.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,897.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17512.52","17512.52","17512.52","1 through 10","15175.19","40707.1","case rate",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","1 through 10","6.87","57.95","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","61.00","45.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","33.45","33.45","33.45","1 through 10","6.87","57.95","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","34.57","1 through 10","7.24","47.85","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","1 through 10","7.24","47.85","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","AETNA [1001]","HB CH AETNA HMO / PPO","1575.09","58.3","","2190.90","412.50","9264.59","16","1200.91","2104.89","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.99","58","","1903.20","1903.20","3826.66","1 through 10","1200.91","2104.89","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1688.56","62.5","","2186.25","2186.25","2186.25","32","1200.91","2104.89","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1972.24","73","","5556.60","5556.60","5556.60","1 through 10","1200.91","2104.89","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","WELLPOINT [1015]","HB CH WELLPOINT","2104.89","77.91","","1955.15","885.83","3150.40","26","1200.91","2104.89","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2701.70","2026.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","1602.11","59.3","","831.03","253.22","2394.88","18","1350.85","2119.48","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2701.70","2026.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2119.48","78.45","","2481.69","1563.74","8149.28","1 through 10","1350.85","2119.48","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","AETNA [1001]","HB CH AETNA HMO / PPO","1918.07","58.3","","2190.90","412.50","9264.59","16","1462.41","2563.24","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1908.20","58","","1903.20","1903.20","3826.66","1 through 10","1462.41","2563.24","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2056.25","62.5","","2186.25","2186.25","2186.25","32","1462.41","2563.24","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2401.70","73","","5556.60","5556.60","5556.60","1 through 10","1462.41","2563.24","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","WELLPOINT [1015]","HB CH WELLPOINT","2563.24","77.91","","1955.15","885.83","3150.40","26","1462.41","2563.24","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3290.00","2467.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1950.97","59.3","","831.03","253.22","2394.88","18","1645","2581.01","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3290.00","2467.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2581.01","78.45","","2481.69","1563.74","8149.28","1 through 10","1645","2581.01","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","AETNA [1001]","HB CH AETNA HMO / PPO","2349.47","58.3","","2190.90","412.50","9264.59","16","1791.32","3139.75","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2337.38","58","","1903.20","1903.20","3826.66","1 through 10","1791.32","3139.75","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2518.73","62.5","","2186.25","2186.25","2186.25","32","1791.32","3139.75","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2941.88","73","","5556.60","5556.60","5556.60","1 through 10","1791.32","3139.75","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","WELLPOINT [1015]","HB CH WELLPOINT","3139.75","77.91","","1955.15","885.83","3150.40","26","1791.32","3139.75","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4029.97","3022.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","2389.77","59.3","","831.03","253.22","2394.88","18","2014.99","3161.51","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4029.97","3022.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3161.51","78.45","","2481.69","1563.74","8149.28","1 through 10","2014.99","3161.51","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","AETNA [1001]","HB CH AETNA HMO / PPO","1964.13","58.3","","1857.49","1857.49","1857.49","14","592.29","2459.37","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","803.10","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3241.37","3241.37","3241.37","1 through 10","592.29","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($816).","1346.10","608.10","3200.00","1 through 10","592.29","2459.37","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","MEDICARE [2001]","HB NWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7016.77","2987.45","9433.02","12","592.29","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9266.55","3082.45","9266.55","1 through 10","592.29","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3083.66","2928.71","3083.96","197","592.29","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2642.98","78.45","","3276.00","1492.55","10171.96","1 through 10","380.6","2642.98","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3369.00","2526.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1997.82","59.3","","2020.50","1919.73","6824.17","145","1997.82","1997.82","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1244.00","933.00","AETNA [1001]","HB CH AETNA HMO / PPO","725.25","58.3","","686.07","686.07","686.07","1 through 10","312.38","908.12","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1244.00","933.00","MEDICARE [2001]","HB NWH MEDICARE","328.79","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","328.82","328.82","328.82","1 through 10","312.38","908.12","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","MEDICARE [2001]","HB NWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5974.90","5974.90","5974.90","1 through 10","322.25","552.96","other","OPPS APC"
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","339.00","254.25","AETNA [1001]","HB CH AETNA HMO / PPO","197.64","58.3","","187.11","187.11","187.11","1 through 10","179.67","264.11","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","196.62","58","","188.97","188.97","188.97","1 through 10","179.67","264.11","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","206.45","60.9","","187.04","187.04","187.04","1 through 10","179.67","264.11","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","211.88","62.5","","208.24","202.21","208.24","11","179.67","264.11","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","339.00","254.25","WELLPOINT [1015]","HB CH WELLPOINT","264.11","77.91","","259.91","259.91","259.91","1 through 10","179.67","264.11","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","outpatient","","","339.00","254.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.03","59.3","","193.38","193.38","193.38","1 through 10","150.69","265.95","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","outpatient","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.69","44.45","","150.35","150.35","150.35","1 through 10","150.69","265.95","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","outpatient","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","265.95","78.45","","253.70","253.70","253.70","1 through 10","150.69","265.95","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","317.00","237.75","AETNA [1001]","HB CH AETNA HMO / PPO","184.81","58.3","","174.64","174.64","174.64","1 through 10","168.01","246.97","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","183.86","58","","158.69","158.69","158.69","1 through 10","168.01","246.97","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","193.05","60.9","","158.69","158.69","158.69","1 through 10","168.01","246.97","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.13","62.5","","169.81","169.81","169.81","1 through 10","168.01","246.97","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","outpatient","","","317.00","237.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","187.98","59.3","","180.49","180.49","180.49","1 through 10","140.91","248.69","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.88","749.16","AETNA [1001]","HB CH AETNA HMO / PPO","582.35","58.3","","2190.90","412.50","9264.59","16","444","778.23","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.88","749.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","579.35","58","","1903.20","1903.20","3826.66","1 through 10","444","778.23","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.88","749.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","624.30","62.5","","2186.25","2186.25","2186.25","32","444","778.23","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.88","749.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","729.18","73","","5556.60","5556.60","5556.60","1 through 10","444","778.23","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.88","749.16","WELLPOINT [1015]","HB CH WELLPOINT","778.23","77.91","","1955.15","885.83","3150.40","26","444","778.23","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.88","749.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","592.34","59.3","","831.03","253.22","2394.88","18","499.44","783.62","percent of total billed charges",""
"ENDCAP ANKLE 12MM PLUS 5MM SURGICAL","SUP-ITM-10033500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.88","749.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","783.62","78.45","","2481.69","1563.74","8149.28","1 through 10","499.44","783.62","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","AETNA [1001]","HB CH AETNA HMO / PPO","280.85","58.3","","464.71","67.87","1012.10","221","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","280.85","58.3","","293.04","293.04","293.04","11","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","255.32","53","","983.89","983.89","983.89","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","279.41","58","","677.18","677.18","677.18","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","301.09","62.5","","46.58","46.58","46.58","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","351.67","73","","747.15","747.15","747.15","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.13","44.45","","1141.67","481.21","1141.67","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.13","44.45","","76.54","76.54","76.54","1 through 10","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","WELLPOINT [1015]","HB CH WELLPOINT","375.32","77.91","","273.64","94.28","1367.51","138","214.13","375.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","285.67","59.3","","720.78","230.14","2010.94","427","240.87","377.93","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","285.67","59.3","","344.45","344.45","344.45","1 through 10","240.87","377.93","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","377.93","78.45","","1120.13","1120.13","1120.13","1 through 10","240.87","377.93","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 10MM EXTENSION T40 STARDRIVE HEAD 9","SUP-ITM-10020727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","377.93","78.45","","456.17","105.33","1284.66","242","240.87","377.93","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","AETNA [1001]","HB CH AETNA HMO / PPO","501.82","58.3","","464.71","67.87","1012.10","221","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","501.82","58.3","","293.04","293.04","293.04","11","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","456.20","53","","983.89","983.89","983.89","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","499.24","58","","677.18","677.18","677.18","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","537.98","62.5","","46.58","46.58","46.58","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","628.35","73","","747.15","747.15","747.15","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.61","44.45","","1141.67","481.21","1141.67","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.61","44.45","","76.54","76.54","76.54","1 through 10","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","860.76","645.57","WELLPOINT [1015]","HB CH WELLPOINT","670.62","77.91","","273.64","94.28","1367.51","138","382.61","670.62","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","510.43","59.3","","720.78","230.14","2010.94","427","430.38","675.27","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","510.43","59.3","","344.45","344.45","344.45","1 through 10","430.38","675.27","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","675.27","78.45","","1120.13","1120.13","1120.13","1 through 10","430.38","675.27","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","860.76","645.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","675.27","78.45","","456.17","105.33","1284.66","242","430.38","675.27","percent of total billed charges",""
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","both","","","2476.00","1857.00","MEDICARE [2001]","HB NWH MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.36","541.36","541.36","1 through 10","744.89","1807.48","other","OPPS APC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2405.00","1803.75","AETNA [1001]","HB CH AETNA HMO / PPO","1402.12","58.3","","1326.21","1326.21","1326.21","1 through 10","744.89","1755.65","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2405.00","1803.75","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","744.89","1755.65","other","OPPS APC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2405.00","1803.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","744.89","1755.65","per diem",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2405.00","1803.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","744.89","1755.65","per diem",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2405.00","1803.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1230.03","1230.03","1 through 10","744.89","1886.72","other","ASC "
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2405.00","1803.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1206.18","1231.73","1 through 10","744.89","1886.72","other","ASC "
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","AETNA [1001]","HB CH AETNA HMO / PPO","5238.26","58.3","","3470.61","3470.61","3470.61","1 through 10","3854.57","7000.21","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","3854.57","7000.21","per diem",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4408.94","49.07","","4833.11","4833.11","4833.11","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4501.49","50.1","","4839.81","4839.81","4839.81","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","5328.11","59.3","","3498.42","3498.42","3498.42","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7048.73","78.45","","4705.82","4705.82","4705.82","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Nasal Diagnostic","PX-76000756","CDM","31231","CPT","0761","RC","","","","both","","","505.00","378.75","AETNA [1001]","HB CH AETNA HMO / PPO","294.42","58.3","","1735.30","1735.30","1735.30","1 through 10","66.29","393.45","percent of total billed charges",""
"Endo Nasal Diagnostic","PX-76000756","CDM","31231","CPT","0761","RC","","","","outpatient","","","505.00","378.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","187.51","","Case rate ($187.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","132.57","132.57","132.57","1 through 10","163.97","567.68","other","ASC "
"Endo Nasal/Sinus W/Control Bleeding","PX-76000760","CDM","31238","CPT","0761","RC","","","","both","","","4192.00","3144.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3068.73","3068.73","3068.73","1 through 10","173.66","3265.99","other","Multiple Surgery"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","297.36","49.07","","1257.55","1257.55","1257.55","1 through 10","297.36","7178","percent of total billed charges",""
"Endo Small Intest Ablation Tumor","PX-75000144","CDM","44369","CPT","0750","RC","","","","both","","","4144.00","3108.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2037.24","2037.24","2037.24","1 through 10","1335.02","3025.12","other","OPPS APC"
"Endo Small Intest Control Bleed","PX-75000143","CDM","44366","CPT","0750","RC","","","","both","","","4144.00","3108.00","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","3025.12","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","2798.00","2098.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2043.55","2043.55","2043.55","1 through 10","1243.71","2906.42","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","2798.00","2098.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1243.71","2906.42","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","2798.00","2098.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1243.71","2906.42","per diem",""
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","2798.00","2098.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2401.96","1 through 10","1335.02","4472.66","other","ASC "
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","2814.00","2110.50","AETNA [1001]","HB CH AETNA HMO / PPO","1640.56","58.3","","1551.31","1551.31","1551.31","1 through 10","1250.82","2906.42","percent of total billed charges",""
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","2814.00","2110.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1250.82","2906.42","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","outpatient","","","2814.00","2110.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","outpatient","","","2814.00","2110.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","AETNA [1001]","HB CH AETNA HMO / PPO","701.35","58.3","","464.71","67.87","1012.10","221","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","701.35","58.3","","293.04","293.04","293.04","11","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","637.59","53","","983.89","983.89","983.89","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","697.74","58","","677.18","677.18","677.18","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","751.88","62.5","","46.58","46.58","46.58","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","878.19","73","","747.15","747.15","747.15","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","1141.67","481.21","1141.67","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","76.54","76.54","76.54","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","WELLPOINT [1015]","HB CH WELLPOINT","937.26","77.91","","273.64","94.28","1367.51","138","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","713.38","59.3","","720.78","230.14","2010.94","427","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","713.38","59.3","","344.45","344.45","344.45","1 through 10","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","1120.13","1120.13","1120.13","1 through 10","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 25MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","456.17","105.33","1284.66","242","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","AETNA [1001]","HB CH AETNA HMO / PPO","701.35","58.3","","464.71","67.87","1012.10","221","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","701.35","58.3","","293.04","293.04","293.04","11","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","637.59","53","","983.89","983.89","983.89","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","697.74","58","","677.18","677.18","677.18","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","751.88","62.5","","46.58","46.58","46.58","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","878.19","73","","747.15","747.15","747.15","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","1141.67","481.21","1141.67","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","534.73","44.45","","76.54","76.54","76.54","1 through 10","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.00","902.25","WELLPOINT [1015]","HB CH WELLPOINT","937.26","77.91","","273.64","94.28","1367.51","138","534.73","937.26","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","713.38","59.3","","720.78","230.14","2010.94","427","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","713.38","59.3","","344.45","344.45","344.45","1 through 10","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","1120.13","1120.13","1120.13","1 through 10","601.5","943.75","percent of total billed charges",""
"ENDOBUTTON FIXATION 30MM KNEE BONE TO BONE CONTINUOUS LOOP","SUP-ITM-10049531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.00","902.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","943.75","78.45","","456.17","105.33","1284.66","242","601.5","943.75","percent of total billed charges",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9146.95","","Case rate ($8,880.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,122.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,264.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,620.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,201.88. The transfer operating threshold is the transfer adjustment factor * $9,122.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.64. The transfer capital threshold is the transfer adjustment factor * $678.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9259.76","9259.76","9259.76","1 through 10","8702.92","10521.63","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10195.58","10195.58","10195.58","1 through 10","8702.92","10521.63","case rate",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","HUMANA [1012]","HB NWH MEDICARE","9764.36","","Case rate ($9,764.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,122.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,264.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,620.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,085.72. The transfer operating threshold is the transfer adjustment factor * $9,122.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.64. The transfer capital threshold is the transfer adjustment factor * $678.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8811.29","8811.29","8811.29","1 through 10","8702.92","10521.63","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","MEDICARE [2001]","HB NWH MEDICARE","9764.36","","Case rate ($9,764.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,122.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,264.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,620.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,085.72. The transfer operating threshold is the transfer adjustment factor * $9,122.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.64. The transfer capital threshold is the transfer adjustment factor * $678.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9862.94","8702.94","9880.67","32","8702.92","10521.63","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8702.92","","Case rate ($8,880.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,122.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,264.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,620.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,201.88. The transfer operating threshold is the transfer adjustment factor * $9,122.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.64. The transfer capital threshold is the transfer adjustment factor * $678.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7806.25","7806.25","7806.25","1 through 10","8702.92","10521.63","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","24020.16","18015.12","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8702.92","","Case rate ($8,880.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,122.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,264.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,620.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,201.88. The transfer operating threshold is the transfer adjustment factor * $9,122.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.64. The transfer capital threshold is the transfer adjustment factor * $678.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8839.29","8839.29","8839.29","1 through 10","8702.92","10521.63","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","34425.14","25818.85","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14689.54","","Case rate ($14,261.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,650.62, add-ons for qualifying new technology services are included. If operating cost exceeds $59,792.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,031.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,171.83. The transfer operating threshold is the transfer adjustment factor * $14,650.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.86. The transfer capital threshold is the transfer adjustment factor * $1,089.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14837.53","14837.53","14837.53","1 through 10","13976.46","16897.22","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","34425.14","25818.85","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15681.08","","Case rate ($15,681.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,650.62, add-ons for qualifying new technology services are included. If operating cost exceeds $59,792.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,031.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,591.22. The transfer operating threshold is the transfer adjustment factor * $14,650.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.86. The transfer capital threshold is the transfer adjustment factor * $1,089.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15592.44","15592.44","15592.44","1 through 10","13976.46","16897.22","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","34425.14","25818.85","MEDICARE [2001]","HB NWH MEDICARE","15681.08","","Case rate ($15,681.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,650.62, add-ons for qualifying new technology services are included. If operating cost exceeds $59,792.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,031.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,591.22. The transfer operating threshold is the transfer adjustment factor * $14,650.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.86. The transfer capital threshold is the transfer adjustment factor * $1,089.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15817.55","9507.59","15845.98","22","13976.46","16897.22","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","34425.14","25818.85","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13976.46","","Case rate ($14,261.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,650.62, add-ons for qualifying new technology services are included. If operating cost exceeds $59,792.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,031.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,171.83. The transfer operating threshold is the transfer adjustment factor * $14,650.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.86. The transfer capital threshold is the transfer adjustment factor * $1,089.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14136.98","14126.70","14164.71","1 through 10","13976.46","16897.22","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","34425.14","25818.85","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13976.46","","Case rate ($14,261.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,650.62, add-ons for qualifying new technology services are included. If operating cost exceeds $59,792.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,031.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,171.83. The transfer operating threshold is the transfer adjustment factor * $14,650.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,089.86. The transfer capital threshold is the transfer adjustment factor * $1,089.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14138.49","14138.49","14419.37","1 through 10","13976.46","16897.22","other","Inpatient DRG"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","16741.45","12556.09","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6656.50","","Case rate ($6,656.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,838.03, add-ons for qualifying new technology services are included. If operating cost exceeds $51,980.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,450.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,147.81. The transfer operating threshold is the transfer adjustment factor * $6,838.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.68. The transfer capital threshold is the transfer adjustment factor * $508.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6717.12","6717.12","6717.12","1 through 10","6523.37","7700.5643","other","Inpatient Replacement Plans DRG"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","16741.45","12556.09","MEDICARE [2001]","HB NWH MEDICARE","6656.50","","Case rate ($6,656.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,838.03, add-ons for qualifying new technology services are included. If operating cost exceeds $51,980.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,450.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,147.81. The transfer operating threshold is the transfer adjustment factor * $6,838.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.68. The transfer capital threshold is the transfer adjustment factor * $508.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7445.41","7445.41","7445.41","1 through 10","6523.37","7700.5643","other","Inpatient Replacement Plans DRG"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","16741.45","12556.09","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6523.37","","Case rate ($6,656.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,838.03, add-ons for qualifying new technology services are included. If operating cost exceeds $51,980.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,450.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,147.81. The transfer operating threshold is the transfer adjustment factor * $6,838.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.68. The transfer capital threshold is the transfer adjustment factor * $508.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6658.58","6655.60","6671.10","1 through 10","6523.37","7700.5643","other","Inpatient DRG"
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB CH AETNA HMO / PPO","59.47","58.3","","56.13","56.13","56.13","1 through 10","11.85","97","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","65.64","63.16","65.64","1 through 10","11.85","97","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","58.01","58.01","58.01","11","30.67","80.02","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","58.85","57.7","","59.70","59.70","114.15","1 through 10","30.67","80.02","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61.71","60.5","","62.67","62.67","74.65","1 through 10","30.67","80.02","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.02","78.45","","76.11","45.10","76.11","1 through 10","30.67","80.02","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2610.00","1957.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1280.73","49.07","","1257.55","1257.55","1257.55","1 through 10","1280.73","7178","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3269.00","2451.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1604.10","49.07","","1257.55","1257.55","1257.55","1 through 10","1604.1","7178","percent of total billed charges",""
"Enzyme Activity Nonradioact Substr","PX-30000415","CDM","82657","CPT","0301","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","1 through 10","18.62","135.72","percent of total billed charges",""
"Epistaxis Without McC","151","MS-DRG","","","","","","","","inpatient","","","16720.59","12540.44","MEDICARE [2001]","HB NWH MEDICARE","6992.23","","Case rate ($6,992.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,532.75, add-ons for qualifying new technology services are included. If operating cost exceeds $51,675.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,427.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,506.26. The transfer operating threshold is the transfer adjustment factor * $6,532.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $485.97. The transfer capital threshold is the transfer adjustment factor * $485.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1555.86","934.96","4378.47","1 through 10","6232.13","7534.51","other","Inpatient DRG"
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","81.00","60.75","AETNA [1001]","HB CH AETNA HMO / PPO","47.22","58.3","","44.79","44.79","44.79","1 through 10","12.86","77.42","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","46.29","46.29","46.29","1 through 10","13.53","82.69","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","28","14.98","114.95","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","18.42","18.42","18.42","1 through 10","14.98","114.95","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","90.72","90.72","90.72","1 through 10","14.98","114.95","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","18","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","90.72","23","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","133.81","54","17.78","114.95","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","43.72","43.72","43.72","1 through 10","17.78","114.95","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","90.72","90.72","90.72","1 through 10","17.78","114.95","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","138.30","29","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","181.44","39","14.72","94.92","percent of total billed charges",""
"Ercp Destruct Calculi Any Method","PX-75000114","CDM","43265","CPT","0750","RC","","","","both","","","6501.00","4875.75","MEDICARE [2001]","HB NWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6220.28","6220.28","6220.28","1 through 10","3445.53","7280.66","other","OPPS APC"
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","both","","","6310.00","4732.50","MEDICARE [2001]","HB NWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2542.22","4916.12","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","5548.00","4161.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6956.21","6956.21","6956.21","1 through 10","2466.09","7280.66","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","5548.00","4161.00","MEDICARE [2001]","HB NWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","6220.28","7069.32","1 through 10","2466.09","7280.66","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","5548.00","4161.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","24391.48","6930.93","24391.48","1 through 10","2466.09","7280.66","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","5548.00","4161.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6935.64","6935.64","6935.64","1 through 10","2466.09","7280.66","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","5548.00","4161.00","WELLPOINT [1015]","HB CH WELLPOINT","4322.45","77.91","","4249.10","4249.10","4249.10","1 through 10","2466.09","7280.66","percent of total billed charges",""
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","5548.00","4161.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7280.38","7280.38","7280.38","1 through 10","2774","5141.51","other","ASC "
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","5548.00","4161.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3289.96","59.3","","3161.47","3161.47","3161.47","1 through 10","2774","5141.51","percent of total billed charges",""
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","both","","","6501.00","4875.75","MEDICARE [2001]","HB NWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2542.22","5064.93","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","4610.00","3457.50","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4153.56","2252.79","4153.56","1 through 10","2140.15","3591.65","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,609). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","3218.00","1 through 10","2140.15","3591.65","per diem",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","4610.00","3457.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2208.73","2208.73","2208.73","1 through 10","2140.15","3591.65","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4670.85","4670.85","4670.85","1 through 10","2049.15","4472.66","other","ASC "
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","5577.00","4182.75","MEDICARE [2001]","HB NWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","6220.28","7069.32","1 through 10","2478.98","7280.66","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","5577.00","4182.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6929.93","6929.93","6929.93","1 through 10","2478.98","7280.66","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","5577.00","4182.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6935.64","6095.88","6935.64","1 through 10","2478.98","7280.66","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","5577.00","4182.75","WELLPOINT [1015]","HB CH WELLPOINT","4345.04","77.91","","4271.15","4271.15","4271.15","1 through 10","2478.98","7280.66","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","5577.00","4182.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7280.38","7280.38","7280.38","1 through 10","2788.5","5141.51","other","ASC "
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","5577.00","4182.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","28527.54","28527.54","28527.54","1 through 10","2788.5","5141.51","other","Multiple Surgery"
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","both","","","6310.00","4732.50","MEDICARE [2001]","HB NWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13554.33","13554.33","13554.33","1 through 10","2542.22","4916.12","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","5029.00","3771.75","AETNA [1001]","HB CH AETNA HMO / PPO","2931.91","58.3","","2772.63","2772.63","2772.63","1 through 10","2235.39","4653.18","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","5029.00","3771.75","MEDICARE [2001]","HB NWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4179.88","13554.33","1 through 10","2235.39","4653.18","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","5029.00","3771.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4433.85","4433.85","4433.85","1 through 10","2235.39","4653.18","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","5029.00","3771.75","WELLPOINT [1015]","HB CH WELLPOINT","3918.09","77.91","","3851.36","3851.36","3851.36","1 through 10","2235.39","4653.18","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","5029.00","3771.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4573.95","4573.95","4573.95","1 through 10","2514.5","4472.66","other","ASC "
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","5029.00","3771.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4670.85","2286.98","4670.85","1 through 10","2514.5","4472.66","other","ASC "
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","5029.00","3771.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2982.20","59.3","","6640.24","2865.54","6640.24","1 through 10","2514.5","4472.66","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","5029.00","3771.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2987.11","2987.11","2987.11","1 through 10","2514.5","4472.66","other","Multiple Surgery"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","AETNA [1001]","HB CH AETNA HMO / PPO","2917.33","58.3","","2759.02","2759.02","2759.02","1 through 10","2224.28","4653.18","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","MEDICARE [2001]","HB NWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13554.33","4518.11","13554.33","1 through 10","2224.28","4653.18","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","5466.00","5466.00","5466.00","1 through 10","2224.28","4653.18","per diem",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4435.15","4435.15","4435.15","1 through 10","2224.28","4653.18","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4104.19","4104.19","4104.19","1 through 10","2224.28","4653.18","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","5004.00","3753.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2286.98","2286.98","2286.98","1 through 10","2502","4472.66","other","ASC "
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","5004.00","3753.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2335.43","2335.43","2335.43","1 through 10","2502","4472.66","other","ASC "
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","5004.00","3753.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5974.22","5974.22","5974.22","1 through 10","2502","4472.66","other","Multiple Surgery"
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","156.00","117.00","AETNA [1001]","HB CH AETNA HMO / PPO","90.95","58.3","","86.18","86.18","86.18","1 through 10","18.41","148.2","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.34","44.45","","69.25","69.25","69.25","1 through 10","18.41","148.2","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","156.00","117.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","1 through 10","19.39","122.38","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","116.86","116.86","116.86","1 through 10","19.39","122.38","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","2302.00","1726.50","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1890.36","630.12","1890.36","1 through 10","598.61","1793.49","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","outpatient","","","2302.00","1726.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1805.92","78.45","","1720.57","1720.57","1720.57","1 through 10","581.71","1805.92","percent of total billed charges",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11318.11","","Case rate ($10,988.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,148.73. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11502.93","11502.93","11527.87","1 through 10","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12082.09","","Case rate ($12,082.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,242.36. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11080.18","11076.69","12085.04","1 through 10","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","26588.97","26588.97","26588.97","1 through 10","10768.69","13019.1","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","MEDICARE [2001]","HB NWH MEDICARE","12082.09","","Case rate ($12,082.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,242.36. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12259.49","12259.33","12281.54","81","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10768.69","","Case rate ($10,988.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,148.73. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10958.33","10958.33","10958.33","1 through 10","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","10768.69","","Case rate ($10,988.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,148.73. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12184.14","12184.14","12184.14","1 through 10","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29413.49","22060.12","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","10768.69","","Case rate ($10,988.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,288.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,430.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,781.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,148.73. The transfer operating threshold is the transfer adjustment factor * $11,288.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.73. The transfer capital threshold is the transfer adjustment factor * $839.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10988.50","10988.50","10988.50","1 through 10","10768.69","13019.1","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6957.03","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6999.68","6988.41","7003.59","1 through 10","6619.31","7716.3867","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6754.40","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7341.35","6730.92","7341.35","1 through 10","6619.31","7716.3867","other","Inpatient Replacement Plans DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7050.10","7050.10","7050.10","1 through 10","6619.31","7716.3867","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","MEDICARE [2001]","HB NWH MEDICARE","6754.40","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7447.33","7447.24","7460.72","125","6619.31","7716.3867","other","Inpatient Replacement Plans DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6619.31","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6661.25","6657.14","6683.87","1 through 10","6619.31","7716.3867","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6619.31","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7763.24","7763.24","7959.10","1 through 10","6619.31","7716.3867","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","17953.20","13464.90","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6619.31","","Case rate ($6,754.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,938.60, add-ons for qualifying new technology services are included. If operating cost exceeds $52,080.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,458.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,238.23. The transfer operating threshold is the transfer adjustment factor * $6,938.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.16. The transfer capital threshold is the transfer adjustment factor * $516.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6671.33","6653.25","18003.88","1 through 10","6619.31","7716.3867","other","Inpatient DRG"
"Esophagoscopy Flex Transoral Dx","PX-75000072","CDM","43200","CPT","0750","RC","","","","outpatient","","","2174.00","1630.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","1231.42","1231.42","1 through 10","761.55","1873.9","other","ASC "
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","outpatient","","","3406.00","2554.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2398.57","1 through 10","1335.02","2672.01","other","ASC "
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","830.96","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","817.66","817.66","817.66","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.66","817.66","817.66","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","814.26","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.67","817.67","817.67","1 through 10","789.41","4711.25","other","OPPS APC"
"Estradiol Free, Serum (Includes Estradiol and Shbg)","PX-30003606","CDM","84999","CPT","0301","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","0.78","78.45","","38.44","38.44","38.44","1 through 10","0.49","28.31","percent of total billed charges",""
"Estriol","PX-30000425","CDM","82677","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","1 through 10","19.13","119.24","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","outpatient","","","265.00","198.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","157.15","59.3","","151.19","151.19","151.19","1 through 10","33.31","207.89","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","outpatient","","","206.00","154.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.16","59.3","","117.20","117.20","117.20","1 through 10","25.74","161.61","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","161.61","78.45","","153.76","153.76","153.76","1 through 10","25.74","161.61","percent of total billed charges",""
"Eua Pelvic Exam","PX-76001359","CDM","57410","CPT","0761","RC","","","","both","","","4625.00","3468.75","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1984.13","3888.77","other","OPPS APC"
"Eua Pelvic Exam","PX-76001359","CDM","57410","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","4472.66","other","Multiple Surgery"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","2617.00","1962.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.12","50.1","","248.00","248.00","248.00","1 through 10","1122.69","2053.04","percent of total billed charges",""
"Eval Cervicovag Pamg-1 Pp12 Alpha-F","PX-30000623","CDM","84112","CPT","0301","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","511.25","511.25","511.25","1 through 10","66.42","536.6","percent of total billed charges",""
"Evaluate Speech Production","PX-44000059","CDM","92522","CPT","0444","RC","","","","both","","","509.00","381.75","AETNA [1001]","HB CH AETNA HMO / PPO","296.75","58.3","","280.67","280.67","280.67","1 through 10","117.48","483.55","percent of total billed charges",""
"Exam Otolaryngologic","PX-76001673","CDM","92502","CPT","0761","RC","","","","both","","","987.00","740.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","774.30","78.45","","4589.74","4589.74","4589.74","1 through 10","423.42","774.3","percent of total billed charges",""
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3845.67","3845.67","3845.67","1 through 10","2140.46","7178","other","ASC "
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3932.70","3851.11","3932.70","1 through 10","2140.46","7178","other","ASC "
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","3384.99","2343.98","3384.99","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1984.13","3888.77","other","OPPS APC"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1984.13","3888.77","per diem",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3708.27","3708.27","3708.27","1 through 10","1984.13","3888.77","other","OPPS APC"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","WELLPOINT [1015]","HB CH WELLPOINT","3603.34","77.91","","8806.94","8806.94","8806.94","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3818.15","3818.15","3818.15","1 through 10","2125.14","4472.66","other","ASC "
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1911.78","1911.78","1911.78","1 through 10","2125.14","4472.66","other","ASC "
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4802.82","2497.04","4994.08","1 through 10","2125.14","4472.66","other","Multiple Surgery"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","7082.30","7082.30","7082.30","1 through 10","2125.14","4472.66","percent of total billed charges",""
"Exc Lesion Intranasal Internal Appr","PX-76000745","CDM","30117","CPT","0761","RC","","","","both","","","4094.00","3070.50","AETNA [1001]","HB CH AETNA HMO / PPO","2386.80","58.3","","7478.16","7478.16","7478.16","1 through 10","444.4","3773.93","percent of total billed charges",""
"Exc Lesion Palate Uvula","PX-75000048","CDM","42104","CPT","0761","RC","","","","outpatient","","","4094.00","3070.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4719.13","4719.13","4719.13","1 through 10","2008.14","4472.66","other","Multiple Surgery"
"Exc Lesion Palate Uvula Closure","PX-75000049","CDM","42106","CPT","0761","RC","","","","both","","","4316.00","3237.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1851.56","3362.6","per diem",""
"Exc Lesion Tongue W/O Clsr","PX-75000030","CDM","41110","CPT","0761","RC","","","","outpatient","","","4316.00","3237.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1806.52","1806.52","1806.52","1 through 10","1873.9","3385.9","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","469.06","469.06","469.06","1 through 10","476.5","970.06","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3522.00","3522.00","3522.00","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","479.00","938.11","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","957.99","957.99","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1375.76","59.3","","8884.93","8884.93","8884.93","1 through 10","579.34","1873.9","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2227.31","2227.31","2227.31","1 through 10","1160","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2156.00","1617.00","AETNA [1001]","HB CH AETNA HMO / PPO","1256.95","58.3","","4949.91","1996.97","4949.91","1 through 10","924.92","1981.66","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1278.51","59.3","","4442.47","4442.47","4442.47","1 through 10","1078","1873.9","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2140.46","4549.94","per diem",""
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","both","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3330.54","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3039.25","3039.25","3039.25","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","4581.48","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3463.12","59.3","","6462.41","6462.41","6462.41","1 through 10","2140.46","4581.48","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1306.00","979.50","AETNA [1001]","HB CH AETNA HMO / PPO","761.40","58.3","","1996.97","1996.97","1996.97","1 through 10","560.27","1017.5","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","8268.00","938.11","8268.00","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1306.00","979.50","AETNA [1001]","HB CH AETNA HMO / PPO","761.40","58.3","","1996.97","1996.97","1996.97","1 through 10","560.27","2122.35","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1306.00","979.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","560.27","2122.35","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","11104.00","11104.00","11104.00","1 through 10","653","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2227.31","2274.50","1 through 10","653","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","774.46","59.3","","6190.84","6190.84","6190.84","1 through 10","653","1873.9","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","3854.00","2890.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3002.65","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","3854.00","2890.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","1237.95","3002.65","per diem",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","3854.00","2890.50","AETNA [1001]","HB CH AETNA HMO / PPO","2246.88","58.3","","4949.91","4949.91","4949.91","1 through 10","1237.95","3002.65","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","3854.00","2890.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","1237.95","3002.65","per diem",""
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1306.00","979.50","AETNA [1001]","HB CH AETNA HMO / PPO","761.40","58.3","","3470.61","3470.61","3470.61","1 through 10","314.08","1017.5","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8268.00","8268.00","8268.00","1 through 10","314.08","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","738.09","738.09","738.09","1 through 10","314.08","1024.56","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1072.00","804.00","AETNA [1001]","HB CH AETNA HMO / PPO","624.98","58.3","","2047.44","1996.97","2047.44","1 through 10","459.89","860.54","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","479.00","469.06","957.99","1 through 10","536","970.06","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","635.70","59.3","","7717.99","7717.99","7717.99","1 through 10","536","970.06","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3002.65","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3216.00","1135.68","11028.00","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3032.40","1113.66","3032.40","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8268.00","8268.00","8268.00","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","938.11","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1306.00","979.50","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","560.27","1017.5","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","938.11","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2285.42","59.3","","4554.69","4554.69","4554.69","1 through 10","1237.95","3023.46","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 3.1-4.0cm","PX-76000078","CDM","11624","CPT","0761","RC","","","","both","","","3854.00","2890.50","MEDICARE [2001]","HB NWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3002.65","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","2876.00","2157.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","957.99","957.99","1 through 10","579.34","4472.66","other","ASC "
"Exc Nail & Matrix","PX-76000092","CDM","11750","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","508.58","508.58","508.58","1 through 10","314.08","970.06","other","ASC "
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","AETNA [1001]","HB CH AETNA HMO / PPO","3404.72","58.3","","2995.46","2995.46","2995.46","1 through 10","2140.46","4549.94","percent of total billed charges",""
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB NWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3567.01","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3331.88","3331.88","3331.88","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","WELLPOINT [1015]","HB CH WELLPOINT","4549.94","77.91","","10387.66","10387.66","10387.66","1 through 10","2140.46","4549.94","percent of total billed charges",""
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3845.67","3845.67","3845.67","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3932.70","3851.11","3932.70","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5030.08","5030.08","5030.08","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5094.29","5094.29","5094.29","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.48","78.45","","6356.44","6356.44","6356.44","1 through 10","2140.46","7939.38","percent of total billed charges",""
"Exc Tmr Nck/Chst Deep <5cm","PX-76000344","CDM","21556","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3463.12","59.3","","4845.05","4845.05","4845.05","1 through 10","2336","4581.48","percent of total billed charges",""
"Exc Tum Face/Scalp Subfasc 2 +","PX-76000313","CDM","21014","CPT","0761","RC","","","","outpatient","","","2724.00","2043.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","1362","2719.71","other","ASC "
"Exc Tum Face/Scalp Subfasc 2 +","PX-76000313","CDM","21014","CPT","0761","RC","","","","outpatient","","","2724.00","2043.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1615.33","59.3","","4845.05","4845.05","4845.05","1 through 10","1362","2719.71","percent of total billed charges",""
"Exc Tum Face/Scalp Subfasc 2 +","PX-76000313","CDM","21014","CPT","0761","RC","","","","outpatient","","","2724.00","2043.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5030.08","5030.08","5030.08","1 through 10","1362","2719.71","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6157.00","4617.75","AETNA [1001]","HB CH AETNA HMO / PPO","3589.53","58.3","","9899.82","7478.16","9899.82","1 through 10","2140.46","4796.92","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6157.00","4617.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5543.79","5543.79","5543.79","1 through 10","2140.46","4796.92","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6157.00","4617.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","2140.46","4796.92","per diem",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3932.70","3932.70","3932.70","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5030.08","5030.08","5030.08","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB NWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3101.27","3101.27","3101.27","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","both","","","5840.00","4380.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3567.01","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3331.88","3331.88","3331.88","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","15090.24","15090.24","15090.24","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6292.95","5286.94","6292.95","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.48","78.45","","3766.90","3766.90","3766.90","1 through 10","2140.46","7939.38","percent of total billed charges",""
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1237.95","4549.94","per diem",""
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1889.50","1889.50","1 through 10","1237.95","4549.94","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2271.35","2224.17","2271.35","1 through 10","1237.95","7939.38","other","ASC "
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","7939.38","other","ASC "
"Exc Tumor Back/Flank Subq 3cm or Gr|BILATERAL PROCEDURE","PX-76000353","CDM","21931","CPT","0761","RC","","","50","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2359.44","","Case rate ($2,359.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","2359.44","14767.25","other","ASC "
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","3951.00","2963.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3206.29","3206.29","3206.29","1 through 10","1237.95","3078.22","other","Multiple Surgery"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","3951.00","2963.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","1237.95","3078.22","other","OPPS APC"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","3951.00","2963.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1137.25","1137.25","1137.25","1 through 10","1237.95","4472.66","other","ASC "
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","3951.00","2963.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","3951.00","2963.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3099.56","78.45","","8123.14","8123.14","8123.14","1 through 10","1237.95","4472.66","percent of total billed charges",""
"Exc Tumor Pelvis/Hip Subq 3+","PX-76000522","CDM","27043","CPT","0761","RC","","","","both","","","6157.00","4617.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3330.54","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3338.79","3338.79","3338.79","1 through 10","2140.46","4796.92","other","OPPS APC"
"Exc Tumor Soft Tiss Back/Flank Subfascial <5cm","PX-36000143","CDM","21932","CPT","0361","RC","","","","both","","","4063.00","3047.25","MEDICARE [2001]","HB NWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","2140.46","3500.47","other","OPPS APC"
"Exc Tumor Soft Tiss Back/Flank Subfascial <5cm","PX-36000143","CDM","21932","CPT","0361","RC","","","","both","","","4063.00","3047.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","2140.46","3500.47","per diem",""
"Exc Tumor Soft Tiss Upper Arm/Elbow Subq <3cm","PX-36000422","CDM","24075","CPT","0361","RC","","","","both","","","4833.00","3624.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","6165.00","6165.00","6165.00","1 through 10","1237.95","3765.39","other","Multiple Surgery"
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1078","1873.9","other","ASC "
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","753.00","564.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","4316.26","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1148.74","1148.74","1148.74","1 through 10","334.71","4316.26","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","753.00","564.75","MEDICARE [2001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","334.71","4316.26","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","753.00","564.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4108.15","3700.44","4109.15","1 through 10","334.71","4316.26","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","753.00","564.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4107.16","3707.45","4114.66","1 through 10","334.71","4316.26","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","753.00","564.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","6233.59","6233.59","6233.59","1 through 10","376.5","3370.43","other","Multiple Surgery"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","753.00","564.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","590.73","78.45","","562.76","562.76","562.76","1 through 10","376.5","3370.43","percent of total billed charges",""
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I","PX-76002187","CDM","50435","CPT","0761","RC","","","","both","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2385.10","2384.08","2391.58","1 through 10","232.47","2505.46","other","OPPS APC"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I|BILATERAL PROCEDURE","PX-76002187","CDM","50435","CPT","0761","RC","","","50","outpatient","","","523.00","392.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2984.25","","Case rate ($2,984.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4309.26","4309.26","4309.26","1 through 10","2984.25","5801.21","other","ASC "
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4123.00","3092.25","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","3212.23","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4123.00","3092.25","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","6758.37","29","1335.02","3212.23","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4123.00","3092.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1335.02","3212.23","per diem",""
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4123.00","3092.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2213.13","2207.73","2213.13","1 through 10","1335.02","3212.23","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4123.00","3092.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.44","2215.24","2215.44","1 through 10","1335.02","3212.23","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4123.00","3092.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","1199.29","2398.57","1 through 10","1335.02","3234.49","other","ASC "
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4123.00","3092.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2401.96","2452.85","1 through 10","1335.02","3234.49","other","ASC "
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4123.00","3092.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2444.94","59.3","","7047.81","2349.27","7047.81","1 through 10","1335.02","3234.49","percent of total billed charges",""
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4123.00","3092.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","3234.49","other","Multiple Surgery"
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","1873.9","3187.42","other","ASC "
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","13326.00","13326.00","13326.00","1 through 10","1873.9","3187.42","other","ASC "
"Excision Hemorrhoid Thrombosed Ext","PX-75000220","CDM","46320","CPT","0761","RC","","","","outpatient","","","4775.00","3581.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1151.26","1151.26","1151.26","1 through 10","979.79","4472.66","other","Multiple Surgery"
"Excision Lesion Tendon Hand/Finger","PX-76000484","CDM","26160","CPT","0761","RC","","","","both","","","4204.00","3153.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1182.01","","Case rate ($1,182.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1533.04","1526.75","1533.04","1 through 10","1182.01","3275.34","other","Multiple Surgery"
"Excision Lesion Tendon Hand/Finger","PX-76000484","CDM","26160","CPT","0761","RC","","","","both","","","4204.00","3153.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1862.38","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1870.47","1864.57","1870.47","1 through 10","1182.01","3275.34","other","OPPS APC"
"Excision Lesion Tendon Hand/Finger","PX-76000484","CDM","26160","CPT","0761","RC","","","","outpatient","","","4204.00","3153.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1182.01","","Case rate ($1,182.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1459.78","1459.78","1459.78","1 through 10","1182.01","7178","other","Multiple Surgery"
"Excision of Ext Anus Papillae/Tags","PX-75000216","CDM","46230","CPT","0750","RC","","","","both","","","5034.00","3775.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1788.00","1788.00","1 through 10","2101.12","3921.99","per diem",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21744.00","16308.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17058.17","78.45","","7551.15","7551.15","7551.15","1 through 10","10872","17058.17","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","2190.90","412.50","9264.59","16","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1872.24","58","","1903.20","1903.20","3826.66","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2017.50","62.5","","2186.25","2186.25","2186.25","32","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","5556.60","5556.60","5556.60","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","1955.15","885.83","3150.40","26","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","831.03","253.22","2394.88","18","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","2481.69","1563.74","8149.28","1 through 10","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","2190.90","412.50","9264.59","16","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1872.24","58","","1903.20","1903.20","3826.66","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2017.50","62.5","","2186.25","2186.25","2186.25","32","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","5556.60","5556.60","5556.60","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","1955.15","885.83","3150.40","26","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","831.03","253.22","2394.88","18","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H14.5CM P6.2CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241077","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","2481.69","1563.74","8149.28","1 through 10","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","2190.90","412.50","9264.59","16","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1872.24","58","","1903.20","1903.20","3826.66","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2017.50","62.5","","2186.25","2186.25","2186.25","32","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","5556.60","5556.60","5556.60","1 through 10","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","1955.15","885.83","3150.40","26","1434.85","2514.93","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","831.03","253.22","2394.88","18","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 650CC W14CM H14.5CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241083","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","2481.69","1563.74","8149.28","1 through 10","1614","2532.37","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","464.71","67.87","1012.10","221","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","293.04","293.04","293.04","11","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","983.89","983.89","983.89","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","391.50","58","","677.18","677.18","677.18","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.88","62.5","","46.58","46.58","46.58","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","747.15","747.15","747.15","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","1141.67","481.21","1141.67","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","76.54","76.54","76.54","1 through 10","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","273.64","94.28","1367.51","138","300.04","525.89","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","720.78","230.14","2010.94","427","337.5","529.54","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.28","59.3","","344.45","344.45","344.45","1 through 10","337.5","529.54","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","1120.13","1120.13","1120.13","1 through 10","337.5","529.54","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","456.17","105.33","1284.66","242","337.5","529.54","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","AETNA [1001]","HB CH AETNA HMO / PPO","1213.89","58.3","","1530.90","1160.93","1884.08","89","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1103.54","53","","5253.92","5253.92","5253.92","1 through 10","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1207.65","58","","12181.47","12181.47","12181.47","1 through 10","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1301.34","62.5","","1350.68","1350.68","1350.68","1 through 10","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","925.52","44.45","","1910.74","891.94","1910.74","1 through 10","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","WELLPOINT [1015]","HB CH WELLPOINT","1622.20","77.91","","1829.79","1561.50","2617.12","88","925.52","1622.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2082.15","1561.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","1234.71","59.3","","1359.46","1201.30","1689.00","61","1041.08","1633.45","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2082.15","1561.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1234.71","59.3","","1718.92","1718.92","1718.92","1 through 10","1041.08","1633.45","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2082.15","1561.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1633.45","78.45","","1910.74","1019.06","2344.84","74","1041.08","1633.45","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","AETNA [1001]","HB CH AETNA HMO / PPO","1658.05","58.3","","1530.90","1160.93","1884.08","89","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1507.32","53","","5253.92","5253.92","5253.92","1 through 10","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1649.52","58","","12181.47","12181.47","12181.47","1 through 10","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1777.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1264.16","44.45","","1910.74","891.94","1910.74","1 through 10","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","WELLPOINT [1015]","HB CH WELLPOINT","2215.76","77.91","","1829.79","1561.50","2617.12","88","1264.16","2215.76","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1686.49","59.3","","1359.46","1201.30","1689.00","61","1422","2231.12","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1686.49","59.3","","1718.92","1718.92","1718.92","1 through 10","1422","2231.12","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2231.12","78.45","","1910.74","1019.06","2344.84","74","1422","2231.12","percent of total billed charges",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","65945.25","","MASSHEALTH [3001]","HB NWH MEDICAID","30626.83","","Case rate ($32,995.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $75,425.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","33080.43","33080.43","33080.43","1 through 10","10892.46","259425.55","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","65945.25","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","29958.28","","Fee schedule rate ($29,958.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29958.28","29958.28","29958.28","1 through 10","10892.46","259425.55","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","950","DRG","","","","","","","","inpatient","","","31064.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","37141.47","","Standard inlier is a Case rate ($37,141.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $47,119, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,272.08) for the length of stay and the standard reimbursement.","37141.47","37141.47","37141.47","1 through 10","10892.46","259425.55","case rate",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","35221.95","26416.46","MEDICARE [2001]","HB NWH MEDICARE","21300.27","","Case rate ($21,300.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,881.16, add-ons for qualifying new technology services are included. If operating cost exceeds $67,023.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,569.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,672.52. The transfer operating threshold is the transfer adjustment factor * $21,881.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.74. The transfer capital threshold is the transfer adjustment factor * $1,627.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23366.68","23366.68","23366.98","1 through 10","20874.26","25236.5","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","35221.95","26416.46","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20874.26","","Case rate ($21,300.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,881.16, add-ons for qualifying new technology services are included. If operating cost exceeds $67,023.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,569.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,672.52. The transfer operating threshold is the transfer adjustment factor * $21,881.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.74. The transfer capital threshold is the transfer adjustment factor * $1,627.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15091.42","15091.42","15091.42","1 through 10","20874.26","25236.5","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","65945.25","49458.94","MEDICARE [2001]","HB NWH MEDICARE","40649.41","","Case rate ($40,649.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $41,757.98, add-ons for qualifying new technology services are included. If operating cost exceeds $86,900.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,048.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $37,543.02. The transfer operating threshold is the transfer adjustment factor * $41,757.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.39. The transfer capital threshold is the transfer adjustment factor * $3,106.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45372.04","20862.06","45453.60","1 through 10","39836.42","47011.3171","other","Inpatient Replacement Plans DRG"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","AETNA [1001]","HB CH AETNA HMO / PPO","293.83","58.3","","277.83","277.83","277.83","1 through 10","44.28","414.21","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","48.16","48.86","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","45.86","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","MEDICARE [2001]","HB NWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","88","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.08","43.29","46.28","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.18","45.68","46.61","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.03","44.45","","223.24","223.24","223.24","1 through 10","44.28","414.21","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","WELLPOINT [1015]","HB CH WELLPOINT","392.67","77.91","","875.92","385.92","875.92","1 through 10","44.28","414.21","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","504.00","378.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","298.87","59.3","","287.14","287.14","374.26","1 through 10","55.54","897.29","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","504.00","378.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","395.39","78.45","","376.71","253.42","514.13","1 through 10","55.54","897.29","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","AETNA [1001]","HB CH AETNA HMO / PPO","798.71","58.3","","755.24","755.24","755.24","1 through 10","44.28","1067.37","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","45.04","48.94","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","43.07","45.86","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","MEDICARE [2001]","HB NWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","43.77","46.61","123","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.08","43.29","46.08","16","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.18","43.07","46.61","16","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","WELLPOINT [1015]","HB CH WELLPOINT","1067.37","77.91","","2381.08","2381.08","2381.08","1 through 10","44.28","1067.37","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1370.00","1027.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","812.41","59.3","","780.55","780.55","780.55","1 through 10","91.36","1074.77","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1370.00","1027.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1074.77","78.45","","980.48","606.86","1024.04","15","91.36","1074.77","percent of total billed charges",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","183943.43","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","375920.48","","Fee schedule rate ($375,920.48). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($43,496.23) multiplied by length of stay and the outlier percent (100%).","106720.64","106720.64","106720.64","1 through 10","2307","375920.48","case rate",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","58429.17","43821.88","MEDICARE [2001]","HB NWH MEDICARE","15457.21","","Case rate ($15,457.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,441.47, add-ons for qualifying new technology services are included. If operating cost exceeds $59,583.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,016.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $14,382.91. The transfer operating threshold is the transfer adjustment factor * $14,441.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.30. The transfer capital threshold is the transfer adjustment factor * $1,074.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15378.51","15378.32","15406.17","1 through 10","13776.92","15934.1457","other","Inpatient DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","93486.28","70114.71","MEDICARE [2001]","HB NWH MEDICARE","31361.20","","Case rate ($31,361.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $29,300.36, add-ons for qualifying new technology services are included. If operating cost exceeds $74,442.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,121.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $29,181.55. The transfer operating threshold is the transfer adjustment factor * $29,300.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,179.66. The transfer capital threshold is the transfer adjustment factor * $2,179.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31752.20","31752.20","31752.20","1 through 10","27952.05","32840.3801","other","Inpatient DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","93486.28","70114.71","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","27952.05","","Case rate ($28,522.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $29,300.36, add-ons for qualifying new technology services are included. If operating cost exceeds $74,442.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,121.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $26,342.85. The transfer operating threshold is the transfer adjustment factor * $29,300.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,179.66. The transfer capital threshold is the transfer adjustment factor * $2,179.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28342.09","28342.09","28342.09","1 through 10","27952.05","32840.3801","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","49885.01","37413.76","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","10184.44","","Case rate ($10,184.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,462.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,604.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,720.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,406.16. The transfer operating threshold is the transfer adjustment factor * $10,462.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.28. The transfer capital threshold is the transfer adjustment factor * $778.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9818.17","9818.17","9818.17","1 through 10","9980.75","11255.6598","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","49885.01","37413.76","MEDICARE [2001]","HB NWH MEDICARE","10184.44","","Case rate ($10,184.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,462.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,604.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,720.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,406.16. The transfer operating threshold is the transfer adjustment factor * $10,462.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.28. The transfer capital threshold is the transfer adjustment factor * $778.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10882.70","10863.03","10882.70","1 through 10","9980.75","11255.6598","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","49885.01","37413.76","MOLINA [1014]","HB NWH MEDICARE","10184.44","","Case rate ($10,184.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,462.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,604.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,720.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,406.16. The transfer operating threshold is the transfer adjustment factor * $10,462.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.28. The transfer capital threshold is the transfer adjustment factor * $778.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9899.79","9899.79","9899.79","1 through 10","9980.75","11255.6598","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","49885.01","37413.76","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9980.75","","Case rate ($10,184.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,462.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,604.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,720.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,406.16. The transfer operating threshold is the transfer adjustment factor * $10,462.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $778.28. The transfer capital threshold is the transfer adjustment factor * $778.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9703.80","9703.80","9703.80","1 through 10","9980.75","11255.6598","other","Inpatient DRG"
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","113","17.57","169.1","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","129.94","73","","505.16","505.16","505.16","1 through 10","17.57","169.1","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","TRICARE [160005]","HB NWH TRICARE","169.10","95","","21.61","21.61","86.44","1 through 10","17.57","169.1","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.12","44.45","","133.00","133.00","133.01","1 through 10","17.57","169.1","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","202.76","70","18.49","139.64","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","18.49","139.64","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","78.82","133.00","99","18.49","139.64","percent of total billed charges",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","16503.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12929.21","","Standard inlier is a Case rate ($12,929.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,912, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,835.35) for the length of stay and the standard reimbursement.","12342.33","12342.33","12342.33","1 through 10","2250","31434.68","case rate",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","16503.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13888.55","","Standard inlier is a Case rate ($13,888.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,912, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,971.42) for the length of stay and the standard reimbursement.","13257.25","13257.25","13257.25","1 through 10","2250","31434.68","case rate",""
"Eye Infections And Other Eye Disorders,MODERATE","082","DRG","","","","","","","","inpatient","","","27047.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15888.17","","Standard inlier is a Case rate ($15,888.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,947, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,255.39) for the length of stay and the standard reimbursement.","15888.17","15888.17","15888.17","1 through 10","2250","31434.68","case rate",""
"Eye Infections And Other Eye Disorders,MODERATE","082","DRG","","","","","","","","inpatient","","","27047.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17067.07","","Standard inlier is a Case rate ($17,067.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,947, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,422.60) for the length of stay and the standard reimbursement.","12218.46","12218.46","12218.46","1 through 10","2250","31434.68","case rate",""
"Eye Infections And Other Eye Disorders,MODERATE","082","DRG","","","","","","","","inpatient","","","27047.44","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7047.26","","Case rate ($7,592.31). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,022.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9514.79","9514.79","9514.79","1 through 10","2250","31434.68","case rate",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","both","","","1514.00","1135.50","AETNA [1001]","HB CH AETNA HMO / PPO","882.66","58.3","","834.62","834.62","834.62","1 through 10","316.25","1935.24","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1514.00","1135.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","897.80","59.3","","862.59","862.59","862.59","1 through 10","672.97","1996.77","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1514.00","1135.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1187.73","78.45","","1131.67","1131.67","1131.67","1 through 10","672.97","1996.77","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2319.00","1739.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","2205.37","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2319.00","1739.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1161.82","50.1","","2255.00","204.62","2255.00","1 through 10","567.68","1819.26","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2319.00","1739.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1819.26","78.45","","1733.64","1733.64","1733.64","1 through 10","567.68","1819.26","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","256.00","192.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","135.68","361.04","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","128.26","50.1","","2255.00","204.62","2255.00","1 through 10","113.79","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.83","78.45","","1733.64","1733.64","1733.64","1 through 10","113.79","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","295.00","221.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","156.35","361.04","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","295.00","221.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","147.80","50.1","","2255.00","204.62","2255.00","1 through 10","131.13","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.43","78.45","","1733.64","1733.64","1733.64","1 through 10","131.13","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","995.00","746.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","946.25","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","995.00","746.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","498.50","50.1","","2255.00","204.62","2255.00","1 through 10","442.28","780.58","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","995.00","746.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","780.58","78.45","","1733.64","1733.64","1733.64","1 through 10","442.28","780.58","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","977.00","732.75","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","929.13","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","977.00","732.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","489.48","50.1","","2255.00","204.62","2255.00","1 through 10","434.28","766.46","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","977.00","732.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","766.46","78.45","","1733.64","1733.64","1733.64","1 through 10","434.28","766.46","percent of total billed charges",""
"Factor II","PX-30001052","CDM","85210","CPT","0305","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","1 through 10","12.72","141.55","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","219.00","164.25","AETNA [1001]","HB CH AETNA HMO / PPO","127.68","58.3","","120.77","120.77","120.77","1 through 10","18.66","208.05","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","outpatient","","","219.00","164.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.87","59.3","","124.82","124.82","124.82","1 through 10","19.63","171.81","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.31","1 through 10","18.2","120.03","percent of total billed charges",""
"Factor VII (Proconvertin) Stable","PX-30001054","CDM","85230","CPT","0305","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","84.29","84.29","84.29","1 through 10","18.47","149.06","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.48","84.48","84.48","1 through 10","17.54","145.35","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB NWH TRICARE","145.35","95","","21.57","21.57","21.57","1 through 10","17.54","145.35","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","114.55","114.55","114.55","1 through 10","17.54","145.35","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.31","1 through 10","18.47","120.03","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","114.55","67.88","114.55","12","18.47","120.03","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","188.00","141.00","AETNA [1001]","HB CH AETNA HMO / PPO","109.60","58.3","","103.76","103.76","103.76","1 through 10","22.48","178.6","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","188.00","141.00","TRICARE [160005]","HB NWH TRICARE","178.60","95","","27.64","27.64","27.64","1 through 10","22.48","178.6","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.57","44.45","","140.69","140.69","140.69","1 through 10","22.48","178.6","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","188.00","141.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","111.48","59.3","","107.24","107.24","107.24","1 through 10","23.65","147.49","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","147.49","78.45","","140.69","83.37","140.69","1 through 10","23.65","147.49","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","189.00","141.75","AETNA [1001]","HB CH AETNA HMO / PPO","110.19","58.3","","104.33","104.33","104.33","1 through 10","22.48","179.55","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","189.00","141.75","TRICARE [160005]","HB NWH TRICARE","179.55","95","","27.64","27.64","27.64","1 through 10","22.48","179.55","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.01","44.45","","141.46","141.46","141.46","1 through 10","22.48","179.55","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","189.00","141.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.08","59.3","","107.82","107.82","107.82","1 through 10","23.65","148.27","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","148.27","78.45","","141.46","83.83","141.46","1 through 10","23.65","148.27","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","both","","","157.00","117.75","AETNA [1001]","HB CH AETNA HMO / PPO","91.53","58.3","","86.75","86.75","86.75","1 through 10","17.54","149.15","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","outpatient","","","157.00","117.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.10","59.3","","89.66","89.66","89.66","1 through 10","18.47","123.17","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","69.71","69.71","69.71","1 through 10","18.47","123.17","percent of total billed charges",""
"Factor XII (Hageman)","PX-30001066","CDM","85280","CPT","0305","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","19.95","173.37","percent of total billed charges",""
"False Labor,MINOR","565","DRG","","","","","","","","inpatient","","","10682.13","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","4612.67","","Fee schedule rate ($4,612.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4612.68","4612.68","4612.68","1 through 10","1993","7248.45","case rate",""
"Familial Mediterranean Fever Boston Univ Fmf","PX-31001333","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","AETNA [1001]","HB CH AETNA HMO / PPO","1061.64","58.3","","1004.16","1004.16","1004.16","1 through 10","269.33","1729.95","percent of total billed charges",""
"Familial Mediterranean Fever Boston Univ Fmf","PX-31001333","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","WELLPOINT [1015]","HB CH WELLPOINT","1418.74","77.91","","1394.84","1394.84","1394.84","1 through 10","269.33","1729.95","percent of total billed charges",""
"Familial Mediterranean Fever Boston Univ Fmf","PX-31001333","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1079.85","59.3","","1037.81","1037.81","1037.81","1 through 10","677.46","1428.57","percent of total billed charges",""
"Familial Mediterranean Fever Boston Univ Fmf","PX-31001333","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1428.57","78.45","","1361.55","1361.55","1361.55","1 through 10","677.46","1428.57","percent of total billed charges",""
"Fat/Lipids Feces Qn","PX-30000431","CDM","82710","CPT","0301","RC","","","","both","","","140.00","105.00","AETNA [1001]","HB CH AETNA HMO / PPO","81.62","58.3","","77.11","77.11","77.11","1 through 10","16.46","133","percent of total billed charges",""
"Fat/Lipids Feces Qn","PX-30000431","CDM","82710","CPT","0301","RC","","","","outpatient","","","140.00","105.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.02","59.3","","239.10","79.70","239.10","1 through 10","17.33","109.83","percent of total billed charges",""
"Fat/Lipids Feces Qn","PX-30000431","CDM","82710","CPT","0301","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.83","78.45","","104.56","104.56","104.56","1 through 10","17.33","109.83","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","68.61","1 through 10","18.39","117.8","percent of total billed charges",""
"Fatty Acids Very Long Chain","PX-30000434","CDM","82726","CPT","0301","RC","","","","outpatient","","","208.00","156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","163.18","78.45","","155.30","155.30","155.30","1 through 10","18.62","163.18","percent of total billed charges",""
"Female Reproductive System Infections,MAJOR","531","DRG","","","","","","","","inpatient","","","14881.05","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8340.41","","Case rate ($8,985.48). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,415.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11260.73","11260.73","11260.73","1 through 10","4210.1","36413.15","case rate",""
"Female Reproductive System Infections,MINOR","531","DRG","","","","","","","","inpatient","","","23016.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11683.85","","Standard inlier is a Case rate ($11,683.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,634, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,658.57) for the length of stay and the standard reimbursement.","16828.63","16828.63","16828.63","1 through 10","4210.1","36413.15","case rate",""
"Female Reproductive System Infections,MINOR","531","DRG","","","","","","","","inpatient","","","23016.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12550.78","","Standard inlier is a Case rate ($12,550.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,634, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,781.53) for the length of stay and the standard reimbursement.","12550.78","12550.78","12550.78","1 through 10","4210.1","36413.15","case rate",""
"Female Reproductive System Infections,MINOR","531","DRG","","","","","","","","inpatient","","","23016.85","","MASSHEALTH [3001]","HB NWH MEDICAID","4430.10","","Case rate ($4,772.73). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,202.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4785.00","4785.00","4785.00","1 through 10","4210.1","36413.15","case rate",""
"Female Reproductive System Malignancy,EXTREME","530","DRG","","","","","","","","inpatient","","","16295.04","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12102.3606","","Fee schedule rate ($47,537.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12102.3606","47537.86","47537.86","1 through 10","8523.19","78436.75","case rate",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","AETNA [1001]","HB CH AETNA HMO / PPO","2086.56","58.3","","1530.90","1160.93","1884.08","89","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.87","53","","5253.92","5253.92","5253.92","1 through 10","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2075.82","58","","12181.47","12181.47","12181.47","1 through 10","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2236.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.87","44.45","","1910.74","891.94","1910.74","1 through 10","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","WELLPOINT [1015]","HB CH WELLPOINT","2788.40","77.91","","1829.79","1561.50","2617.12","88","1590.87","2788.4","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2122.35","59.3","","1359.46","1201.30","1689.00","61","1789.5","2807.73","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2122.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1789.5","2807.73","percent of total billed charges",""
"FEMORAL COMPONENT 62.5MM VANGUARD XP INTERLOC RIGHT KNEE","SUP-ITM-10208469","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2807.73","78.45","","1910.74","1019.06","2344.84","74","1789.5","2807.73","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1530.90","1160.93","1884.08","89","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","5253.92","5253.92","5253.92","1 through 10","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","12181.47","12181.47","12181.47","1 through 10","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1910.74","891.94","1910.74","1 through 10","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","1829.79","1561.50","2617.12","88","1466.85","2571.03","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1359.46","1201.30","1689.00","61","1650","2588.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1718.92","1718.92","1718.92","1 through 10","1650","2588.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA POSTERIOR STABILIZED CEMENTED RT","SUP-ITM-10051575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1910.74","1019.06","2344.84","74","1650","2588.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1530.90","1160.93","1884.08","89","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","5253.92","5253.92","5253.92","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2125.70","58","","12181.47","12181.47","12181.47","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2290.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.09","44.45","","1910.74","891.94","1910.74","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","1829.79","1561.50","2617.12","88","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1359.46","1201.30","1689.00","61","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 5 SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10118558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","1910.74","1019.06","2344.84","74","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1530.90","1160.93","1884.08","89","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","5253.92","5253.92","5253.92","1 through 10","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2131.50","58","","12181.47","12181.47","12181.47","1 through 10","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2296.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","1910.74","891.94","1910.74","1 through 10","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","1829.79","1561.50","2617.12","88","1633.54","2863.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1359.46","1201.30","1689.00","61","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 L PSN CRUCIATING CEMENTED NARROW","SUP-ITM-10295911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","1910.74","1019.06","2344.84","74","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1530.90","1160.93","1884.08","89","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","5253.92","5253.92","5253.92","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2125.70","58","","12181.47","12181.47","12181.47","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2290.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.09","44.45","","1910.74","891.94","1910.74","1 through 10","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","1829.79","1561.50","2617.12","88","1629.09","2855.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1359.46","1201.30","1689.00","61","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 NARROW RT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","1910.74","1019.06","2344.84","74","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1530.90","1160.93","1884.08","89","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","5253.92","5253.92","5253.92","1 through 10","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2880.57","58","","12181.47","12181.47","12181.47","1 through 10","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3104.06","62.5","","1350.68","1350.68","1350.68","1 through 10","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2207.61","44.45","","1910.74","891.94","1910.74","1 through 10","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","1829.79","1561.50","2617.12","88","2207.61","3869.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1359.46","1201.30","1689.00","61","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307929","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","1910.74","1019.06","2344.84","74","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1530.90","1160.93","1884.08","89","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","5253.92","5253.92","5253.92","1 through 10","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","12181.47","12181.47","12181.47","1 through 10","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","1350.68","1350.68","1350.68","1 through 10","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1910.74","891.94","1910.74","1 through 10","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","1829.79","1561.50","2617.12","88","560.07","981.67","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1359.46","1201.30","1689.00","61","630","988.47","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","1718.92","1718.92","1718.92","1 through 10","630","988.47","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1910.74","1019.06","2344.84","74","630","988.47","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","AETNA [1001]","HB CH AETNA HMO / PPO","949.71","58.3","","1530.90","1160.93","1884.08","89","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","863.37","53","","5253.92","5253.92","5253.92","1 through 10","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","944.82","58","","12181.47","12181.47","12181.47","1 through 10","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1018.13","62.5","","1350.68","1350.68","1350.68","1 through 10","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","724.09","44.45","","1910.74","891.94","1910.74","1 through 10","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","WELLPOINT [1015]","HB CH WELLPOINT","1269.15","77.91","","1829.79","1561.50","2617.12","88","724.09","1269.15","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1629.00","1221.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","966.00","59.3","","1359.46","1201.30","1689.00","61","814.5","1277.95","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1629.00","1221.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","966.00","59.3","","1718.92","1718.92","1718.92","1 through 10","814.5","1277.95","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1629.00","1221.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1277.95","78.45","","1910.74","1019.06","2344.84","74","814.5","1277.95","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","AETNA [1001]","HB CH AETNA HMO / PPO","1780.48","58.3","","1530.90","1160.93","1884.08","89","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1618.62","53","","5253.92","5253.92","5253.92","1 through 10","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1771.32","58","","12181.47","12181.47","12181.47","1 through 10","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1908.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.50","44.45","","1910.74","891.94","1910.74","1 through 10","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","WELLPOINT [1015]","HB CH WELLPOINT","2379.37","77.91","","1829.79","1561.50","2617.12","88","1357.5","2379.37","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1359.46","1201.30","1689.00","61","1527","2395.86","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1718.92","1718.92","1718.92","1 through 10","1527","2395.86","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2395.86","78.45","","1910.74","1019.06","2344.84","74","1527","2395.86","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","AETNA [1001]","HB CH AETNA HMO / PPO","2457.78","58.3","","1530.90","1160.93","1884.08","89","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2234.35","53","","5253.92","5253.92","5253.92","1 through 10","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2445.14","58","","12181.47","12181.47","12181.47","1 through 10","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2634.84","62.5","","1350.68","1350.68","1350.68","1 through 10","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1873.90","44.45","","1910.74","891.94","1910.74","1 through 10","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4215.75","3161.81","WELLPOINT [1015]","HB CH WELLPOINT","3284.49","77.91","","1829.79","1561.50","2617.12","88","1873.9","3284.49","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4215.75","3161.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2499.94","59.3","","1359.46","1201.30","1689.00","61","2107.88","3307.26","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4215.75","3161.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2499.94","59.3","","1718.92","1718.92","1718.92","1 through 10","2107.88","3307.26","percent of total billed charges",""
"FEMORAL HEAD 36MM MINUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4215.75","3161.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3307.26","78.45","","1910.74","1019.06","2344.84","74","2107.88","3307.26","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"FEMORAL HEAD 40MM DIA 12/14 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION TAPERED PLUS","SUP-ITM-10114318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1530.90","1160.93","1884.08","89","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","5253.92","5253.92","5253.92","1 through 10","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","12181.47","12181.47","12181.47","1 through 10","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1910.74","891.94","1910.74","1 through 10","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1829.79","1561.50","2617.12","88","533.4","934.92","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1359.46","1201.30","1689.00","61","600","941.4","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","1718.92","1718.92","1718.92","1 through 10","600","941.4","percent of total billed charges",""
"FEMORAL HEAD 40MM M +0MM CERAMIC","SUP-ITM-10317771","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1910.74","1019.06","2344.84","74","600","941.4","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","AETNA [1001]","HB CH AETNA HMO / PPO","1985.12","58.3","","1530.90","1160.93","1884.08","89","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1804.65","53","","5253.92","5253.92","5253.92","1 through 10","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1974.90","58","","12181.47","12181.47","12181.47","1 through 10","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2128.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1513.52","44.45","","1910.74","891.94","1910.74","1 through 10","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","WELLPOINT [1015]","HB CH WELLPOINT","2652.84","77.91","","1829.79","1561.50","2617.12","88","1513.52","2652.84","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2019.17","59.3","","1359.46","1201.30","1689.00","61","1702.5","2671.22","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2019.17","59.3","","1718.92","1718.92","1718.92","1 through 10","1702.5","2671.22","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2671.22","78.45","","1910.74","1019.06","2344.84","74","1702.5","2671.22","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","both","","","6414.10","4810.57","AETNA [1001]","HB CH AETNA HMO / PPO","3739.42","58.3","","2190.90","412.50","9264.59","16","2851.07","4997.23","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","both","","","6414.10","4810.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3720.18","58","","1903.20","1903.20","3826.66","1 through 10","2851.07","4997.23","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","both","","","6414.10","4810.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4008.81","62.5","","2186.25","2186.25","2186.25","32","2851.07","4997.23","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","both","","","6414.10","4810.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4682.29","73","","5556.60","5556.60","5556.60","1 through 10","2851.07","4997.23","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","both","","","6414.10","4810.57","WELLPOINT [1015]","HB CH WELLPOINT","4997.23","77.91","","1955.15","885.83","3150.40","26","2851.07","4997.23","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6414.10","4810.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","3803.56","59.3","","831.03","253.22","2394.88","18","3207.05","5031.86","percent of total billed charges",""
"FEMORAL SPACER 13MM RING ALLOGRAFT WITH LATERAL SLOT ANGLED 8DD","SUP-ITM-10048778","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6414.10","4810.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5031.86","78.45","","2481.69","1563.74","8149.28","1 through 10","3207.05","5031.86","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","1530.90","1160.93","1884.08","89","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4240.00","53","","5253.92","5253.92","5253.92","1 through 10","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4640.00","58","","12181.47","12181.47","12181.47","1 through 10","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5000.00","62.5","","1350.68","1350.68","1350.68","1 through 10","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3556.00","44.45","","1910.74","891.94","1910.74","1 through 10","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","1829.79","1561.50","2617.12","88","3556","6232.8","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","1359.46","1201.30","1689.00","61","4000","6276","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4744.00","59.3","","1718.92","1718.92","1718.92","1 through 10","4000","6276","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","1910.74","1019.06","2344.84","74","4000","6276","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1530.90","1160.93","1884.08","89","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","5253.92","5253.92","5253.92","1 through 10","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","12181.47","12181.47","12181.47","1 through 10","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1910.74","891.94","1910.74","1 through 10","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","1829.79","1561.50","2617.12","88","1600.2","2804.76","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1359.46","1201.30","1689.00","61","1800","2824.2","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1800","2824.2","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1910.74","1019.06","2344.84","74","1800","2824.2","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"FEMORAL STEM SZ 9 KLASSIC BLADE OFFSET POROUS","SUP-ITM-10283265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","464.71","67.87","1012.10","221","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","293.04","293.04","293.04","11","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","983.89","983.89","983.89","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1270.20","58","","677.18","677.18","677.18","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1368.75","62.5","","46.58","46.58","46.58","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","747.15","747.15","747.15","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","1141.67","481.21","1141.67","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","76.54","76.54","76.54","1 through 10","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","273.64","94.28","1367.51","138","973.46","1706.23","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","720.78","230.14","2010.94","427","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1298.67","59.3","","344.45","344.45","344.45","1 through 10","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","1120.13","1120.13","1120.13","1 through 10","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 15.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10011676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","456.17","105.33","1284.66","242","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","AETNA [1001]","HB CH AETNA HMO / PPO","1902.17","58.3","","464.71","67.87","1012.10","221","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1902.17","58.3","","293.04","293.04","293.04","11","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1729.25","53","","983.89","983.89","983.89","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1892.38","58","","677.18","677.18","677.18","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2039.21","62.5","","46.58","46.58","46.58","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2381.79","73","","747.15","747.15","747.15","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.28","44.45","","1141.67","481.21","1141.67","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.28","44.45","","76.54","76.54","76.54","1 through 10","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.73","2447.05","WELLPOINT [1015]","HB CH WELLPOINT","2541.99","77.91","","273.64","94.28","1367.51","138","1450.28","2541.99","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.73","2447.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1934.80","59.3","","720.78","230.14","2010.94","427","1631.37","2559.61","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.73","2447.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1934.80","59.3","","344.45","344.45","344.45","1 through 10","1631.37","2559.61","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.73","2447.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2559.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1631.37","2559.61","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.73","2447.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2559.61","78.45","","456.17","105.33","1284.66","242","1631.37","2559.61","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","AETNA [1001]","HB CH AETNA HMO / PPO","2018.35","58.3","","464.71","67.87","1012.10","221","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2018.35","58.3","","293.04","293.04","293.04","11","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1834.86","53","","983.89","983.89","983.89","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2007.96","58","","677.18","677.18","677.18","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2163.75","62.5","","46.58","46.58","46.58","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2527.26","73","","747.15","747.15","747.15","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.86","44.45","","1141.67","481.21","1141.67","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.86","44.45","","76.54","76.54","76.54","1 through 10","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","WELLPOINT [1015]","HB CH WELLPOINT","2697.24","77.91","","273.64","94.28","1367.51","138","1538.86","2697.24","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2052.97","59.3","","720.78","230.14","2010.94","427","1731","2715.94","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2052.97","59.3","","344.45","344.45","344.45","1 through 10","1731","2715.94","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2715.94","78.45","","1120.13","1120.13","1120.13","1 through 10","1731","2715.94","percent of total billed charges",""
"FEMUR PLATE 91MM MD 11 HOLE LEG ORTHOLOC 3DI TITANIUM LATERAL FIBULA RIGHT","SUP-ITM-10132150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2715.94","78.45","","456.17","105.33","1284.66","242","1731","2715.94","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1530.90","1160.93","1884.08","89","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","5253.92","5253.92","5253.92","1 through 10","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4539.08","58","","12181.47","12181.47","12181.47","1 through 10","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4891.25","62.5","","1350.68","1350.68","1350.68","1 through 10","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3478.66","44.45","","1910.74","891.94","1910.74","1 through 10","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","1829.79","1561.50","2617.12","88","3478.66","6097.24","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1359.46","1201.30","1689.00","61","3913","6139.5","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1718.92","1718.92","1718.92","1 through 10","3913","6139.5","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","1910.74","1019.06","2344.84","74","3913","6139.5","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","AETNA [1001]","HB CH AETNA HMO / PPO","90.95","58.3","","86.18","86.18","86.18","555","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","113.88","73","","110.96","110.96","110.96","1 through 10","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.68","53","","80.56","80.56","80.56","1 through 10","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.88","73","","89.07","86.18","108.04","1 through 10","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","TRICARE [160005]","HB NWH TRICARE","148.20","95","","16.42","15.60","16.42","14","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.34","44.45","","116.86","69.25","116.86","24","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.34","44.45","","116.86","116.86","116.86","1 through 10","13.36","148.2","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","569","14.05","122.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","116.86","116.86","116.86","1 through 10","14.05","122.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","116.86","69.25","116.86","494","14.05","122.38","percent of total billed charges",""
"Fetal Congenital Abnor Three Anal","PX-31000190","CDM","81510","CPT","0310","RC","","","","outpatient","","","743.00","557.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","440.60","59.3","","292.41","292.41","292.41","1 through 10","362.58","582.88","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","both","","","544.00","408.00","AETNA [1001]","HB CH AETNA HMO / PPO","317.15","58.3","","299.94","299.94","299.94","1 through 10","63.12","516.8","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","544.00","408.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","426.77","78.45","","406.70","241.01","406.70","1 through 10","66.42","426.77","percent of total billed charges",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","18947.64","14210.73","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7690.97","","Case rate ($7,690.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,900.71, add-ons for qualifying new technology services are included. If operating cost exceeds $53,042.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,529.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,103.23. The transfer operating threshold is the transfer adjustment factor * $7,900.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.74. The transfer capital threshold is the transfer adjustment factor * $587.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8448.68","8448.68","8448.68","1 through 10","7537.15","8880.322","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","18947.64","14210.73","MEDICARE [2001]","HB NWH MEDICARE","7690.97","","Case rate ($7,690.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,900.71, add-ons for qualifying new technology services are included. If operating cost exceeds $53,042.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,529.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,103.23. The transfer operating threshold is the transfer adjustment factor * $7,900.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.74. The transfer capital threshold is the transfer adjustment factor * $587.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8586.06","8570.65","8586.06","1 through 10","7537.15","8880.322","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","18947.64","14210.73","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7537.15","","Case rate ($7,690.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,900.71, add-ons for qualifying new technology services are included. If operating cost exceeds $53,042.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,529.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,103.23. The transfer operating threshold is the transfer adjustment factor * $7,900.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.74. The transfer capital threshold is the transfer adjustment factor * $587.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7664.80","7664.80","7664.80","1 through 10","7537.15","8880.322","other","Inpatient DRG"
"Fever And Inflammatory Conditions,MAJOR","722","DRG","","","","","","","","inpatient","","","10625.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18503.92","","Standard inlier is a Case rate ($18,503.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,630, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,626.70) for the length of stay and the standard reimbursement.","18973.40","18973.40","18973.40","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MAJOR","722","DRG","","","","","","","","inpatient","","","10625.61","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9452.4654","","Fee schedule rate ($17,775.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9452.4654","17090.48","17090.48","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MAJOR","722","DRG","","","","","","","","inpatient","","","10625.61","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","7937.30","","Fee schedule rate ($7,937.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7937.24","7937.24","7937.24","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MINOR","722","DRG","","","","","","","","inpatient","","","14663.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9719.88","","Standard inlier is a Case rate ($9,719.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,930, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,379.70) for the length of stay and the standard reimbursement.","9278.06","9278.06","9278.06","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MINOR","722","DRG","","","","","","","","inpatient","","","14663.00","","MASSHEALTH [3001]","HB NWH MEDICAID","4015.42","","Case rate ($4,325.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,755.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5421.38","5421.38","5421.38","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MODERATE","722","DRG","","","","","","","","inpatient","","","9461.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14583.77","","Standard inlier is a Case rate ($14,583.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,576, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,070.10) for the length of stay and the standard reimbursement.","14583.76","14583.76","14583.76","1 through 10","3920.63","29329.14","case rate",""
"Fever And Inflammatory Conditions,MODERATE","722","DRG","","","","","","","","inpatient","","","9461.00","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9452.4654","","Fee schedule rate ($11,881.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9452.4654","11881.54","11881.54","1 through 10","3920.63","29329.14","case rate",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","464.71","67.87","1012.10","221","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","293.04","293.04","293.04","11","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","983.89","983.89","983.89","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","677.18","677.18","677.18","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","46.58","46.58","46.58","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","747.15","747.15","747.15","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1141.67","481.21","1141.67","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","76.54","76.54","76.54","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","273.64","94.28","1367.51","138","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","720.78","230.14","2010.94","427","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","344.45","344.45","344.45","1 through 10","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1120.13","1120.13","1120.13","1 through 10","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 CURVED","SUP-ITM-10319379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","456.17","105.33","1284.66","242","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","464.71","67.87","1012.10","221","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","293.04","293.04","293.04","11","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","983.89","983.89","983.89","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","677.18","677.18","677.18","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","46.58","46.58","46.58","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","747.15","747.15","747.15","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1141.67","481.21","1141.67","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","76.54","76.54","76.54","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","273.64","94.28","1367.51","138","733.43","1285.52","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","720.78","230.14","2010.94","427","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","344.45","344.45","344.45","1 through 10","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1120.13","1120.13","1120.13","1 through 10","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.5 REVERSE CURVED","SUP-ITM-10319378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","456.17","105.33","1284.66","242","825","1294.43","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","20","9.98","113.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.90","44.45","","89.18","89.18","89.18","1 through 10","9.98","113.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","67.98","362.78","34","10.5","93.36","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","89.18","52.85","89.18","24","10.5","93.36","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","73.00","54.75","AETNA [1001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","40.26","40.26","1 through 10","9.53","69.35","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","73.00","54.75","TRICARE [160005]","HB NWH TRICARE","69.35","95","","71.00","71.00","71.00","1 through 10","9.53","69.35","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","73.00","54.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.29","59.3","","41.61","41.61","41.61","1 through 10","8.76","57.27","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.27","78.45","","54.58","51.61","54.59","1 through 10","8.76","57.27","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","AETNA [1001]","HB CH AETNA HMO / PPO","1786.34","58.3","","1530.90","1160.93","1884.08","89","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1623.95","53","","5253.92","5253.92","5253.92","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1777.15","58","","12181.47","12181.47","12181.47","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1915.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1361.97","44.45","","1910.74","891.94","1910.74","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","WELLPOINT [1015]","HB CH WELLPOINT","2387.20","77.91","","1829.79","1561.50","2617.12","88","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1816.98","59.3","","1359.46","1201.30","1689.00","61","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1816.98","59.3","","1718.92","1718.92","1718.92","1 through 10","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2403.75","78.45","","1910.74","1019.06","2344.84","74","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","AETNA [1001]","HB CH AETNA HMO / PPO","1268.03","58.3","","464.71","67.87","1012.10","221","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1268.03","58.3","","293.04","293.04","293.04","11","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1152.75","53","","983.89","983.89","983.89","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1261.50","58","","677.18","677.18","677.18","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1359.38","62.5","","46.58","46.58","46.58","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1587.75","73","","747.15","747.15","747.15","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","966.79","44.45","","1141.67","481.21","1141.67","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","966.79","44.45","","76.54","76.54","76.54","1 through 10","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","WELLPOINT [1015]","HB CH WELLPOINT","1694.54","77.91","","273.64","94.28","1367.51","138","966.79","1694.54","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1289.78","59.3","","720.78","230.14","2010.94","427","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1289.78","59.3","","344.45","344.45","344.45","1 through 10","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1706.29","78.45","","1120.13","1120.13","1120.13","1 through 10","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1706.29","78.45","","456.17","105.33","1284.66","242","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","464.71","67.87","1012.10","221","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","293.04","293.04","293.04","11","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","983.89","983.89","983.89","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1383.30","58","","677.18","677.18","677.18","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1490.63","62.5","","46.58","46.58","46.58","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","747.15","747.15","747.15","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","1141.67","481.21","1141.67","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","76.54","76.54","76.54","1 through 10","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","273.64","94.28","1367.51","138","1060.13","1858.15","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","720.78","230.14","2010.94","427","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1414.31","59.3","","344.45","344.45","344.45","1 through 10","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","1120.13","1120.13","1120.13","1 through 10","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","456.17","105.33","1284.66","242","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","AETNA [1001]","HB CH AETNA HMO / PPO","697.36","58.3","","464.71","67.87","1012.10","221","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","697.36","58.3","","293.04","293.04","293.04","11","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","633.96","53","","983.89","983.89","983.89","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","693.77","58","","677.18","677.18","677.18","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","747.60","62.5","","46.58","46.58","46.58","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","873.20","73","","747.15","747.15","747.15","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.69","44.45","","1141.67","481.21","1141.67","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.69","44.45","","76.54","76.54","76.54","1 through 10","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","both","","","1196.16","897.12","WELLPOINT [1015]","HB CH WELLPOINT","931.93","77.91","","273.64","94.28","1367.51","138","531.69","931.93","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1196.16","897.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","709.32","59.3","","720.78","230.14","2010.94","427","598.08","938.39","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1196.16","897.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","709.32","59.3","","344.45","344.45","344.45","1 through 10","598.08","938.39","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1196.16","897.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","938.39","78.45","","1120.13","1120.13","1120.13","1 through 10","598.08","938.39","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL LEFT DISTAL","SUP-ITM-10095098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1196.16","897.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","938.39","78.45","","456.17","105.33","1284.66","242","598.08","938.39","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","AETNA [1001]","HB CH AETNA HMO / PPO","1021.17","58.3","","464.71","67.87","1012.10","221","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1021.17","58.3","","293.04","293.04","293.04","11","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","928.34","53","","983.89","983.89","983.89","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1015.92","58","","677.18","677.18","677.18","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1094.74","62.5","","46.58","46.58","46.58","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1278.65","73","","747.15","747.15","747.15","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.58","44.45","","1141.67","481.21","1141.67","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.58","44.45","","76.54","76.54","76.54","1 through 10","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","1751.58","1313.68","WELLPOINT [1015]","HB CH WELLPOINT","1364.66","77.91","","273.64","94.28","1367.51","138","778.58","1364.66","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1751.58","1313.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1038.69","59.3","","720.78","230.14","2010.94","427","875.79","1374.11","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1751.58","1313.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1038.69","59.3","","344.45","344.45","344.45","1 through 10","875.79","1374.11","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1751.58","1313.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1374.11","78.45","","1120.13","1120.13","1120.13","1 through 10","875.79","1374.11","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1751.58","1313.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1374.11","78.45","","456.17","105.33","1284.66","242","875.79","1374.11","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","AETNA [1001]","HB CH AETNA HMO / PPO","1124.06","58.3","","464.71","67.87","1012.10","221","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1124.06","58.3","","293.04","293.04","293.04","11","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1021.88","53","","983.89","983.89","983.89","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1118.28","58","","677.18","677.18","677.18","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1205.04","62.5","","46.58","46.58","46.58","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1407.49","73","","747.15","747.15","747.15","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.03","44.45","","1141.67","481.21","1141.67","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.03","44.45","","76.54","76.54","76.54","1 through 10","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.07","1446.05","WELLPOINT [1015]","HB CH WELLPOINT","1502.16","77.91","","273.64","94.28","1367.51","138","857.03","1502.16","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.07","1446.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1143.35","59.3","","720.78","230.14","2010.94","427","964.04","1512.57","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.07","1446.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1143.35","59.3","","344.45","344.45","344.45","1 through 10","964.04","1512.57","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.07","1446.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1512.57","78.45","","1120.13","1120.13","1120.13","1 through 10","964.04","1512.57","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.07","1446.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1512.57","78.45","","456.17","105.33","1284.66","242","964.04","1512.57","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","AETNA [1001]","HB CH AETNA HMO / PPO","884.63","58.3","","464.71","67.87","1012.10","221","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","884.63","58.3","","293.04","293.04","293.04","11","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.21","53","","983.89","983.89","983.89","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","880.07","58","","677.18","677.18","677.18","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","948.36","62.5","","46.58","46.58","46.58","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1107.68","73","","747.15","747.15","747.15","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.47","44.45","","1141.67","481.21","1141.67","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.47","44.45","","76.54","76.54","76.54","1 through 10","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.37","1138.03","WELLPOINT [1015]","HB CH WELLPOINT","1182.18","77.91","","273.64","94.28","1367.51","138","674.47","1182.18","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.37","1138.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","899.80","59.3","","720.78","230.14","2010.94","427","758.69","1190.38","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.37","1138.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","899.80","59.3","","344.45","344.45","344.45","1 through 10","758.69","1190.38","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.37","1138.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1190.38","78.45","","1120.13","1120.13","1120.13","1 through 10","758.69","1190.38","percent of total billed charges",""
"FIBULA PLATE 2.7X79MM 3 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.37","1138.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1190.38","78.45","","456.17","105.33","1284.66","242","758.69","1190.38","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","AETNA [1001]","HB CH AETNA HMO / PPO","916.98","58.3","","464.71","67.87","1012.10","221","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","916.98","58.3","","293.04","293.04","293.04","11","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","833.62","53","","983.89","983.89","983.89","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","912.26","58","","677.18","677.18","677.18","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","983.04","62.5","","46.58","46.58","46.58","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1148.20","73","","747.15","747.15","747.15","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","699.14","44.45","","1141.67","481.21","1141.67","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","699.14","44.45","","76.54","76.54","76.54","1 through 10","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1572.87","1179.65","WELLPOINT [1015]","HB CH WELLPOINT","1225.42","77.91","","273.64","94.28","1367.51","138","699.14","1225.42","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1572.87","1179.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","932.71","59.3","","720.78","230.14","2010.94","427","786.44","1233.92","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1572.87","1179.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","932.71","59.3","","344.45","344.45","344.45","1 through 10","786.44","1233.92","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1572.87","1179.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1233.92","78.45","","1120.13","1120.13","1120.13","1 through 10","786.44","1233.92","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1572.87","1179.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1233.92","78.45","","456.17","105.33","1284.66","242","786.44","1233.92","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","AETNA [1001]","HB CH AETNA HMO / PPO","1855.62","58.3","","464.71","67.87","1012.10","221","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1855.62","58.3","","293.04","293.04","293.04","11","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1686.93","53","","983.89","983.89","983.89","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1846.07","58","","677.18","677.18","677.18","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1989.30","62.5","","46.58","46.58","46.58","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2323.50","73","","747.15","747.15","747.15","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1414.79","44.45","","1141.67","481.21","1141.67","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1414.79","44.45","","76.54","76.54","76.54","1 through 10","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3182.88","2387.16","WELLPOINT [1015]","HB CH WELLPOINT","2479.78","77.91","","273.64","94.28","1367.51","138","1414.79","2479.78","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3182.88","2387.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","1887.45","59.3","","720.78","230.14","2010.94","427","1591.44","2496.97","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3182.88","2387.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1887.45","59.3","","344.45","344.45","344.45","1 through 10","1591.44","2496.97","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3182.88","2387.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2496.97","78.45","","1120.13","1120.13","1120.13","1 through 10","1591.44","2496.97","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3182.88","2387.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2496.97","78.45","","456.17","105.33","1284.66","242","1591.44","2496.97","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","AETNA [1001]","HB CH AETNA HMO / PPO","1006.46","58.3","","464.71","67.87","1012.10","221","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1006.46","58.3","","293.04","293.04","293.04","11","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","914.97","53","","983.89","983.89","983.89","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1001.28","58","","677.18","677.18","677.18","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1078.97","62.5","","46.58","46.58","46.58","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1260.24","73","","747.15","747.15","747.15","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","767.36","44.45","","1141.67","481.21","1141.67","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","767.36","44.45","","76.54","76.54","76.54","1 through 10","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1726.35","1294.76","WELLPOINT [1015]","HB CH WELLPOINT","1345.00","77.91","","273.64","94.28","1367.51","138","767.36","1345","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1726.35","1294.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","1023.73","59.3","","720.78","230.14","2010.94","427","863.18","1354.32","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1726.35","1294.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1023.73","59.3","","344.45","344.45","344.45","1 through 10","863.18","1354.32","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1726.35","1294.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1354.32","78.45","","1120.13","1120.13","1120.13","1 through 10","863.18","1354.32","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1726.35","1294.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1354.32","78.45","","456.17","105.33","1284.66","242","863.18","1354.32","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","AETNA [1001]","HB CH AETNA HMO / PPO","893.18","58.3","","464.71","67.87","1012.10","221","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","893.18","58.3","","293.04","293.04","293.04","11","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","811.98","53","","983.89","983.89","983.89","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","888.58","58","","677.18","677.18","677.18","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","957.53","62.5","","46.58","46.58","46.58","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1118.39","73","","747.15","747.15","747.15","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","680.99","44.45","","1141.67","481.21","1141.67","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","680.99","44.45","","76.54","76.54","76.54","1 through 10","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1532.04","1149.03","WELLPOINT [1015]","HB CH WELLPOINT","1193.61","77.91","","273.64","94.28","1367.51","138","680.99","1193.61","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1532.04","1149.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","908.50","59.3","","720.78","230.14","2010.94","427","766.02","1201.89","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1532.04","1149.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","908.50","59.3","","344.45","344.45","344.45","1 through 10","766.02","1201.89","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1532.04","1149.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1201.89","78.45","","1120.13","1120.13","1120.13","1 through 10","766.02","1201.89","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1532.04","1149.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1201.89","78.45","","456.17","105.33","1284.66","242","766.02","1201.89","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","464.71","67.87","1012.10","221","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","293.04","293.04","293.04","11","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","983.89","983.89","983.89","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","677.18","677.18","677.18","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","46.58","46.58","46.58","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","747.15","747.15","747.15","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1141.67","481.21","1141.67","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","76.54","76.54","76.54","1 through 10","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","273.64","94.28","1367.51","138","733.43","1285.52","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","720.78","230.14","2010.94","427","825","1294.43","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","344.45","344.45","344.45","1 through 10","825","1294.43","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1120.13","1120.13","1120.13","1 through 10","825","1294.43","percent of total billed charges",""
"FIBULA PLATE 79MM 4 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","456.17","105.33","1284.66","242","825","1294.43","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","AETNA [1001]","HB CH AETNA HMO / PPO","1786.34","58.3","","464.71","67.87","1012.10","221","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1786.34","58.3","","293.04","293.04","293.04","11","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1623.95","53","","983.89","983.89","983.89","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1777.15","58","","677.18","677.18","677.18","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1915.03","62.5","","46.58","46.58","46.58","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2236.76","73","","747.15","747.15","747.15","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1361.97","44.45","","1141.67","481.21","1141.67","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1361.97","44.45","","76.54","76.54","76.54","1 through 10","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","WELLPOINT [1015]","HB CH WELLPOINT","2387.20","77.91","","273.64","94.28","1367.51","138","1361.97","2387.2","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1816.98","59.3","","720.78","230.14","2010.94","427","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1816.98","59.3","","344.45","344.45","344.45","1 through 10","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2403.75","78.45","","1120.13","1120.13","1120.13","1 through 10","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2403.75","78.45","","456.17","105.33","1284.66","242","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","464.71","67.87","1012.10","221","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1136.85","58.3","","293.04","293.04","293.04","11","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","983.89","983.89","983.89","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1131.00","58","","677.18","677.18","677.18","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1218.75","62.5","","46.58","46.58","46.58","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","747.15","747.15","747.15","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","1141.67","481.21","1141.67","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","76.54","76.54","76.54","1 through 10","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","273.64","94.28","1367.51","138","866.78","1519.25","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","720.78","230.14","2010.94","427","975","1529.78","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1156.35","59.3","","344.45","344.45","344.45","1 through 10","975","1529.78","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","1120.13","1120.13","1120.13","1 through 10","975","1529.78","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","456.17","105.33","1284.66","242","975","1529.78","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","AETNA [1001]","HB CH AETNA HMO / PPO","2363.70","58.3","","464.71","67.87","1012.10","221","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.70","58.3","","293.04","293.04","293.04","11","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.82","53","","983.89","983.89","983.89","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2351.54","58","","677.18","677.18","677.18","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2533.99","62.5","","46.58","46.58","46.58","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","747.15","747.15","747.15","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","1141.67","481.21","1141.67","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","76.54","76.54","76.54","1 through 10","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","WELLPOINT [1015]","HB CH WELLPOINT","3158.77","77.91","","273.64","94.28","1367.51","138","1802.17","3158.77","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.25","59.3","","720.78","230.14","2010.94","427","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2404.25","59.3","","344.45","344.45","344.45","1 through 10","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","1120.13","1120.13","1120.13","1 through 10","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","456.17","105.33","1284.66","242","2027.19","3180.66","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","AETNA [1001]","HB CH AETNA HMO / PPO","668.43","58.3","","464.71","67.87","1012.10","221","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","668.43","58.3","","293.04","293.04","293.04","11","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","607.67","53","","983.89","983.89","983.89","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","664.99","58","","677.18","677.18","677.18","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","716.59","62.5","","46.58","46.58","46.58","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","836.97","73","","747.15","747.15","747.15","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","509.64","44.45","","1141.67","481.21","1141.67","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","509.64","44.45","","76.54","76.54","76.54","1 through 10","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.54","859.90","WELLPOINT [1015]","HB CH WELLPOINT","893.27","77.91","","273.64","94.28","1367.51","138","509.64","893.27","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.54","859.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","679.90","59.3","","720.78","230.14","2010.94","427","573.27","899.46","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.54","859.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","679.90","59.3","","344.45","344.45","344.45","1 through 10","573.27","899.46","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.54","859.90","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","899.46","78.45","","1120.13","1120.13","1120.13","1 through 10","573.27","899.46","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.54","859.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","899.46","78.45","","456.17","105.33","1284.66","242","573.27","899.46","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","AETNA [1001]","HB CH AETNA HMO / PPO","1909.33","58.3","","464.71","67.87","1012.10","221","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1909.33","58.3","","293.04","293.04","293.04","11","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1735.75","53","","983.89","983.89","983.89","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1899.50","58","","677.18","677.18","677.18","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2046.88","62.5","","46.58","46.58","46.58","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2390.75","73","","747.15","747.15","747.15","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.74","44.45","","1141.67","481.21","1141.67","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.74","44.45","","76.54","76.54","76.54","1 through 10","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","WELLPOINT [1015]","HB CH WELLPOINT","2551.55","77.91","","273.64","94.28","1367.51","138","1455.74","2551.55","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1942.08","59.3","","720.78","230.14","2010.94","427","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1942.08","59.3","","344.45","344.45","344.45","1 through 10","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2569.24","78.45","","1120.13","1120.13","1120.13","1 through 10","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2569.24","78.45","","456.17","105.33","1284.66","242","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","AETNA [1001]","HB CH AETNA HMO / PPO","2716.78","58.3","","464.71","67.87","1012.10","221","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2716.78","58.3","","293.04","293.04","293.04","11","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2469.80","53","","983.89","983.89","983.89","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2702.80","58","","677.18","677.18","677.18","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2912.50","62.5","","46.58","46.58","46.58","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3401.80","73","","747.15","747.15","747.15","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2071.37","44.45","","1141.67","481.21","1141.67","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2071.37","44.45","","76.54","76.54","76.54","1 through 10","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","WELLPOINT [1015]","HB CH WELLPOINT","3630.61","77.91","","273.64","94.28","1367.51","138","2071.37","3630.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2763.38","59.3","","720.78","230.14","2010.94","427","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2763.38","59.3","","344.45","344.45","344.45","1 through 10","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3655.77","78.45","","1120.13","1120.13","1120.13","1 through 10","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3655.77","78.45","","456.17","105.33","1284.66","242","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","464.71","67.87","1012.10","221","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","293.04","293.04","293.04","11","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","983.89","983.89","983.89","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1557.30","58","","677.18","677.18","677.18","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1678.13","62.5","","46.58","46.58","46.58","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","747.15","747.15","747.15","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","1141.67","481.21","1141.67","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","76.54","76.54","76.54","1 through 10","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","273.64","94.28","1367.51","138","1193.48","2091.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","720.78","230.14","2010.94","427","1342.5","2106.38","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1592.21","59.3","","344.45","344.45","344.45","1 through 10","1342.5","2106.38","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","1120.13","1120.13","1120.13","1 through 10","1342.5","2106.38","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","456.17","105.33","1284.66","242","1342.5","2106.38","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","AETNA [1001]","HB CH AETNA HMO / PPO","2265.82","58.3","","464.71","67.87","1012.10","221","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2265.82","58.3","","293.04","293.04","293.04","11","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2059.83","53","","983.89","983.89","983.89","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2254.16","58","","677.18","677.18","677.18","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2429.05","62.5","","46.58","46.58","46.58","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2837.13","73","","747.15","747.15","747.15","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1727.54","44.45","","1141.67","481.21","1141.67","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1727.54","44.45","","76.54","76.54","76.54","1 through 10","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3886.48","2914.86","WELLPOINT [1015]","HB CH WELLPOINT","3027.96","77.91","","273.64","94.28","1367.51","138","1727.54","3027.96","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3886.48","2914.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","2304.68","59.3","","720.78","230.14","2010.94","427","1943.24","3048.94","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3886.48","2914.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2304.68","59.3","","344.45","344.45","344.45","1 through 10","1943.24","3048.94","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3886.48","2914.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3048.94","78.45","","1120.13","1120.13","1120.13","1 through 10","1943.24","3048.94","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3886.48","2914.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3048.94","78.45","","456.17","105.33","1284.66","242","1943.24","3048.94","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","AETNA [1001]","HB CH AETNA HMO / PPO","2086.35","58.3","","464.71","67.87","1012.10","221","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2086.35","58.3","","293.04","293.04","293.04","11","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.68","53","","983.89","983.89","983.89","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2075.61","58","","677.18","677.18","677.18","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2236.65","62.5","","46.58","46.58","46.58","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2612.41","73","","747.15","747.15","747.15","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.71","44.45","","1141.67","481.21","1141.67","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.71","44.45","","76.54","76.54","76.54","1 through 10","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.64","2683.98","WELLPOINT [1015]","HB CH WELLPOINT","2788.12","77.91","","273.64","94.28","1367.51","138","1590.71","2788.12","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.64","2683.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2122.13","59.3","","720.78","230.14","2010.94","427","1789.32","2807.44","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.64","2683.98","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2122.13","59.3","","344.45","344.45","344.45","1 through 10","1789.32","2807.44","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.64","2683.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2807.44","78.45","","1120.13","1120.13","1120.13","1 through 10","1789.32","2807.44","percent of total billed charges",""
"FILLER VOID 3CC BONE DRILLABLE STERILE","SUP-ITM-10320108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.64","2683.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2807.44","78.45","","456.17","105.33","1284.66","242","1789.32","2807.44","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","both","","","1201.00","900.75","WELLPOINT [1015]","HB CH WELLPOINT","935.70","77.91","","919.92","919.92","919.92","1 through 10","579.34","935.7","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","957.99","957.99","1 through 10","515.23","970.06","other","ASC "
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-98301812","CDM","10009","CPT","0983","RC","","","","both","","","462.00","346.50","WELLPOINT [1015]","HB CH WELLPOINT","359.94","77.91","","919.92","919.92","919.92","1 through 10","244.86","860.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","AETNA [1001]","HB CH AETNA HMO / PPO","700.18","58.3","","662.26","662.26","662.26","1 through 10","533.84","935.7","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.69","859.79","860.69","1 through 10","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","HUMANA [1012]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","820.01","820.01","820.01","1 through 10","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","38","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","3992.46","1702.00","3992.46","1 through 10","533.84","935.7","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1831.21","1170.18","5139.42","1 through 10","533.84","935.7","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.84","44.45","","532.14","532.14","532.14","1 through 10","533.84","935.7","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","752.54","825.15","1 through 10","533.84","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","956.66","936.79","956.66","1 through 10","579.34","970.06","other","ASC "
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","938.11","957.99","21","579.34","970.06","other","ASC "
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","712.19","59.3","","2210.98","684.45","2573.09","14","579.34","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","1361.45","6807.25","12","579.34","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","942.18","78.45","","897.96","897.95","1079.09","1 through 10","579.34","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","AETNA [1001]","HB CH AETNA HMO / PPO","221.54","58.3","","662.26","662.26","662.26","1 through 10","168.91","860.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.69","859.79","860.69","1 through 10","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","HUMANA [1012]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","820.01","820.01","820.01","1 through 10","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","38","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","3992.46","1702.00","3992.46","1 through 10","168.91","860.54","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1831.21","1170.18","5139.42","1 through 10","168.91","860.54","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","168.91","44.45","","532.14","532.14","532.14","1 through 10","168.91","860.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","752.54","825.15","1 through 10","168.91","860.54","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","225.34","59.3","","2210.98","684.45","2573.09","14","184.74","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","1361.45","6807.25","12","184.74","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","298.11","78.45","","897.96","897.95","1079.09","1 through 10","184.74","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","968.00","726.00","AETNA [1001]","HB CH AETNA HMO / PPO","564.34","58.3","","533.55","533.55","533.55","1 through 10","513.04","754.17","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","outpatient","","","968.00","726.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","759.40","78.45","","723.44","723.44","723.44","1 through 10","83.21","759.4","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","533.55","533.55","533.55","1 through 10","136.74","201.01","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","723.44","723.44","723.44","1 through 10","114.68","202.4","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","AETNA [1001]","HB CH AETNA HMO / PPO","161.49","58.3","","305.05","137.19","305.05","1 through 10","60.28","270.7","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","202.21","73","","196.37","196.37","196.37","1 through 10","60.28","270.7","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","MEDICARE [2001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","63.45","63.45","1 through 10","60.28","270.7","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.13","44.45","","122.56","122.56","122.56","1 through 10","60.28","270.7","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","WELLPOINT [1015]","HB CH WELLPOINT","215.81","77.91","","211.86","211.86","480.86","1 through 10","60.28","270.7","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","277.00","207.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","164.26","59.3","","157.63","157.63","157.64","16","90.37","217.31","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","217.31","78.45","","206.81","122.56","206.81","22","90.37","217.31","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","AETNA [1001]","HB CH AETNA HMO / PPO","3623.93","58.3","","1530.90","1160.93","1884.08","89","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3294.48","53","","5253.92","5253.92","5253.92","1 through 10","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3605.28","58","","12181.47","12181.47","12181.47","1 through 10","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3885.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2763.01","44.45","","1910.74","891.94","1910.74","1 through 10","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","WELLPOINT [1015]","HB CH WELLPOINT","4842.89","77.91","","1829.79","1561.50","2617.12","88","2763.01","4842.89","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1359.46","1201.30","1689.00","61","3108","4876.45","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1718.92","1718.92","1718.92","1 through 10","3108","4876.45","percent of total billed charges",""
"FINGER PROSTHESIS SZ 30 FINGER JOINT METACARPOPHALAGEAL PYROCARBON PROXIMAL","SUP-ITM-10028023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.45","78.45","","1910.74","1019.06","2344.84","74","3108","4876.45","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","AETNA [1001]","HB CH AETNA HMO / PPO","2105.80","58.3","","464.71","67.87","1012.10","221","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2105.80","58.3","","293.04","293.04","293.04","11","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1914.36","53","","983.89","983.89","983.89","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2094.96","58","","677.18","677.18","677.18","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2257.50","62.5","","46.58","46.58","46.58","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2636.76","73","","747.15","747.15","747.15","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","1141.67","481.21","1141.67","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","76.54","76.54","76.54","1 through 10","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","WELLPOINT [1015]","HB CH WELLPOINT","2814.11","77.91","","273.64","94.28","1367.51","138","1605.53","2814.11","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2141.92","59.3","","720.78","230.14","2010.94","427","1806","2833.61","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2141.92","59.3","","344.45","344.45","344.45","1 through 10","1806","2833.61","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1806","2833.61","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","456.17","105.33","1284.66","242","1806","2833.61","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","AETNA [1001]","HB CH AETNA HMO / PPO","2784.41","58.3","","1530.90","1160.93","1884.08","89","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2531.28","53","","5253.92","5253.92","5253.92","1 through 10","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2770.08","58","","12181.47","12181.47","12181.47","1 through 10","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2985.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2122.93","44.45","","1910.74","891.94","1910.74","1 through 10","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","WELLPOINT [1015]","HB CH WELLPOINT","3720.98","77.91","","1829.79","1561.50","2617.12","88","2122.93","3720.98","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4776.00","3582.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2832.17","59.3","","1359.46","1201.30","1689.00","61","2388","3746.77","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4776.00","3582.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2832.17","59.3","","1718.92","1718.92","1718.92","1 through 10","2388","3746.77","percent of total billed charges",""
"FINGER STEM 11.7X2.3 8.6MM SZ 20 JOINT PROXIMALIMAL INTERPHALANGEAL PYROCARBON","SUP-ITM-10012377","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4776.00","3582.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3746.77","78.45","","1910.74","1019.06","2344.84","74","2388","3746.77","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1530.90","1160.93","1884.08","89","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","5253.92","5253.92","5253.92","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2969.60","58","","12181.47","12181.47","12181.47","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3200.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2275.84","44.45","","1910.74","891.94","1910.74","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","1829.79","1561.50","2617.12","88","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1359.46","1201.30","1689.00","61","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1718.92","1718.92","1718.92","1 through 10","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","1910.74","1019.06","2344.84","74","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1530.90","1160.93","1884.08","89","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","5253.92","5253.92","5253.92","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2969.60","58","","12181.47","12181.47","12181.47","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3200.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2275.84","44.45","","1910.74","891.94","1910.74","1 through 10","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","1829.79","1561.50","2617.12","88","2275.84","3988.99","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1359.46","1201.30","1689.00","61","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1718.92","1718.92","1718.92","1 through 10","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D RT 02","SUP-ITM-10012492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","1910.74","1019.06","2344.84","74","2560","4016.64","percent of total billed charges",""
"Flap Delay/Section Eye/Nose/Ear","PX-76000195","CDM","15630","CPT","0761","RC","","","","both","","","4859.00","3644.25","MEDICARE [2001]","HB NWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1548.96","3785.65","other","OPPS APC"
"Flecainide, Serum","PX-30003519","CDM","80299","CPT","0301","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","156.75","percent of total billed charges",""
"Flecainide, Serum","PX-30003519","CDM","80299","CPT","0301","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","125.99","125.99","125.99","1 through 10","14.12","129.44","percent of total billed charges",""
"Flecainide, Serum","PX-30003519","CDM","80299","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","165.29","97.95","215.00","1 through 10","14.12","129.44","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","AETNA [1001]","HB CH AETNA HMO / PPO","117.77","58.3","","111.13","111.13","111.13","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","439.96","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","439.58","439.58","439.58","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.03","386.03","386.03","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","213.60","427.19","67","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.79","44.45","","89.30","89.30","89.30","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","419.44","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","WELLPOINT [1015]","HB CH WELLPOINT","157.38","77.91","","154.37","154.37","154.37","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","202.00","151.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.79","59.3","","196.00","173.16","196.00","1 through 10","101","926.86","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.47","78.45","","150.68","89.30","150.69","12","101","926.86","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","158.76","158.76","158.76","28","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","167.04","58","","73.10","73.10","73.10","1 through 10","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","167.04","58","","86.00","83.51","86.00","1 through 10","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","180.00","62.5","","94.77","94.77","284.31","49","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.02","44.45","","127.57","127.57","127.57","1 through 10","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","220.53","220.53","220.53","1 through 10","128.02","224.38","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","247.36","247.36","247.36","1 through 10","144","225.94","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","215.26","81.45","215.26","106","144","225.94","percent of total billed charges",""
"Flow Cytometry Interp 9-15 Marker","PX-31000104","CDM","88188","CPT","0311","RC","","","","outpatient","","","1537.00","1152.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1205.78","78.45","","1149.36","1149.36","1149.36","1 through 10","125.76","1205.78","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","30","11.81","76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","56.94","56.94","56.94","1 through 10","11.81","76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","TRICARE [160005]","HB NWH TRICARE","76.00","95","","14.52","14.52","14.52","1 through 10","11.81","76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","59.97","59.97","59.97","1 through 10","11.81","76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","172.88","27","8.98","62.76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","45.71","1 through 10","8.98","62.76","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","35.54","59.97","40","8.98","62.76","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1131.00","848.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","866.91","other","OPPS APC"
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","AETNA [1001]","HB CH AETNA HMO / PPO","100.05","58.3","","97.30","97.30","97.30","1 through 10","90.95","728.02","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","123.73","72.1","","128.71","128.71","128.71","1 through 10","90.95","728.02","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","108.80","63.4","","113.78","113.78","113.78","1 through 10","90.95","728.02","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","171.61","128.71","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","103.82","60.5","","108.63","108.63","108.63","1 through 10","76.28","483.39","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","68.61","162","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","90.52","73","","88.33","88.33","88.33","1 through 10","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","90.52","73","","13.23","13.23","13.23","1 through 10","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","TRICARE [160005]","HB NWH TRICARE","117.80","95","","17.71","17.71","17.71","1 through 10","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.12","44.45","","93.02","55.13","93.02","1 through 10","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.12","44.45","","93.02","93.02","93.02","1 through 10","14.41","117.8","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","46","15.17","97.28","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","93.02","55.13","93.02","134","15.17","97.28","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","AETNA [1001]","HB CH AETNA HMO / PPO","127.09","58.3","","120.20","120.20","120.20","169","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","159.14","73","","34.16","34.16","34.16","1 through 10","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","TRICARE [160005]","HB NWH TRICARE","207.10","95","","22.39","21.27","22.39","1 through 10","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","207.10","95","","18.58","18.58","18.58","1 through 10","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.90","44.45","","162.99","96.59","162.99","1 through 10","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.90","44.45","","162.99","162.99","162.99","1 through 10","18.21","207.1","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","218.00","163.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","124.23","124.23","168","19.16","171.02","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.02","78.45","","162.99","96.59","162.99","125","19.16","171.02","percent of total billed charges",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","36083.46","","MASSHEALTH [3001]","HB NWH MEDICAID","14926.15","","Case rate ($16,080.57). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,510.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16121.93","16121.93","16121.93","1 through 10","11264.87","66841.81","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","36083.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","38211.08","","Fee schedule rate ($38,211.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38211.08","38211.08","38211.08","1 through 10","11264.87","66841.81","case rate",""
"Foot And Toe Procedures,MODERATE","314","DRG","","","","","","","","inpatient","","","37329.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20063.7714","","Fee schedule rate ($27,098.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20063.7714","27098.90","27098.90","1 through 10","11264.87","66841.81","case rate",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","AETNA [1001]","HB CH AETNA HMO / PPO","1322.24","58.3","","1530.90","1160.93","1884.08","89","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1202.04","53","","5253.92","5253.92","5253.92","1 through 10","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1315.44","58","","12181.47","12181.47","12181.47","1 through 10","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1417.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1008.13","44.45","","1910.74","891.94","1910.74","1 through 10","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","WELLPOINT [1015]","HB CH WELLPOINT","1767.00","77.91","","1829.79","1561.50","2617.12","88","1008.13","1767","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1344.92","59.3","","1359.46","1201.30","1689.00","61","1134","1779.25","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1344.92","59.3","","1718.92","1718.92","1718.92","1 through 10","1134","1779.25","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.25","78.45","","1910.74","1019.06","2344.84","74","1134","1779.25","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","AETNA [1001]","HB CH AETNA HMO / PPO","1263.84","58.3","","464.71","67.87","1012.10","221","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1263.84","58.3","","293.04","293.04","293.04","11","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1148.95","53","","983.89","983.89","983.89","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1257.34","58","","677.18","677.18","677.18","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1354.89","62.5","","46.58","46.58","46.58","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1582.52","73","","747.15","747.15","747.15","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","963.60","44.45","","1141.67","481.21","1141.67","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","963.60","44.45","","76.54","76.54","76.54","1 through 10","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2167.83","1625.87","WELLPOINT [1015]","HB CH WELLPOINT","1688.96","77.91","","273.64","94.28","1367.51","138","963.6","1688.96","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2167.83","1625.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","1285.52","59.3","","720.78","230.14","2010.94","427","1083.92","1700.66","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2167.83","1625.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1285.52","59.3","","344.45","344.45","344.45","1 through 10","1083.92","1700.66","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2167.83","1625.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1700.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1083.92","1700.66","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2167.83","1625.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1700.66","78.45","","456.17","105.33","1284.66","242","1083.92","1700.66","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","AETNA [1001]","HB CH AETNA HMO / PPO","1268.37","58.3","","464.71","67.87","1012.10","221","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1268.37","58.3","","293.04","293.04","293.04","11","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1153.07","53","","983.89","983.89","983.89","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1261.85","58","","677.18","677.18","677.18","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1359.75","62.5","","46.58","46.58","46.58","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1588.19","73","","747.15","747.15","747.15","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","967.05","44.45","","1141.67","481.21","1141.67","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","967.05","44.45","","76.54","76.54","76.54","1 through 10","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.60","1631.70","WELLPOINT [1015]","HB CH WELLPOINT","1695.01","77.91","","273.64","94.28","1367.51","138","967.05","1695.01","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.60","1631.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","1290.13","59.3","","720.78","230.14","2010.94","427","1087.8","1706.76","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.60","1631.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1290.13","59.3","","344.45","344.45","344.45","1 through 10","1087.8","1706.76","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.60","1631.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1706.76","78.45","","1120.13","1120.13","1120.13","1 through 10","1087.8","1706.76","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.60","1631.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1706.76","78.45","","456.17","105.33","1284.66","242","1087.8","1706.76","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","AETNA [1001]","HB CH AETNA HMO / PPO","1234.72","58.3","","464.71","67.87","1012.10","221","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1234.72","58.3","","293.04","293.04","293.04","11","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1122.48","53","","983.89","983.89","983.89","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1228.37","58","","677.18","677.18","677.18","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1323.68","62.5","","46.58","46.58","46.58","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1546.05","73","","747.15","747.15","747.15","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.40","44.45","","1141.67","481.21","1141.67","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.40","44.45","","76.54","76.54","76.54","1 through 10","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2117.88","1588.41","WELLPOINT [1015]","HB CH WELLPOINT","1650.04","77.91","","273.64","94.28","1367.51","138","941.4","1650.04","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2117.88","1588.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1255.90","59.3","","720.78","230.14","2010.94","427","1058.94","1661.48","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2117.88","1588.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1255.90","59.3","","344.45","344.45","344.45","1 through 10","1058.94","1661.48","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2117.88","1588.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1661.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1058.94","1661.48","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2117.88","1588.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1661.48","78.45","","456.17","105.33","1284.66","242","1058.94","1661.48","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","464.71","67.87","1012.10","221","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","293.04","293.04","293.04","11","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","983.89","983.89","983.89","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","677.18","677.18","677.18","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","46.58","46.58","46.58","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","747.15","747.15","747.15","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1141.67","481.21","1141.67","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","76.54","76.54","76.54","1 through 10","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","273.64","94.28","1367.51","138","800.1","1402.38","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","720.78","230.14","2010.94","427","900","1412.1","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","344.45","344.45","344.45","1 through 10","900","1412.1","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1120.13","1120.13","1120.13","1 through 10","900","1412.1","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","456.17","105.33","1284.66","242","900","1412.1","percent of total billed charges",""
"Foot Procedures With Cc","504","MS-DRG","","","","","","","","inpatient","","","40688.40","30516.30","MEDICARE [2001]","HB NWH MEDICARE","17806.38","","Case rate ($17,806.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,636.27, add-ons for qualifying new technology services are included. If operating cost exceeds $61,778.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,179.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,568.80. The transfer operating threshold is the transfer adjustment factor * $16,636.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,237.58. The transfer capital threshold is the transfer adjustment factor * $1,237.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16780.13","16750.01","16780.13","1 through 10","15870.72","17806.38","other","Inpatient DRG"
"Foot Procedures Without Cc/McC","505","MS-DRG","","","","","","","","inpatient","","","25996.73","19497.55","MEDICARE [2001]","HB NWH MEDICARE","17078.58","","Case rate ($17,078.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,956.29, add-ons for qualifying new technology services are included. If operating cost exceeds $61,098.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,128.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $15,891.58. The transfer operating threshold is the transfer adjustment factor * $15,956.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.99. The transfer capital threshold is the transfer adjustment factor * $1,186.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16780.13","16780.13","16780.13","1 through 10","15222.04","17355.195","other","Inpatient DRG"
"Foot Procedures Without Cc/McC","505","MS-DRG","","","","","","","","inpatient","","","25996.73","19497.55","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15222.04","","Case rate ($15,532.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,956.29, add-ons for qualifying new technology services are included. If operating cost exceeds $61,098.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,128.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,345.69. The transfer operating threshold is the transfer adjustment factor * $15,956.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,186.99. The transfer capital threshold is the transfer adjustment factor * $1,186.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14959.48","14959.48","14959.48","1 through 10","15222.04","17355.195","other","Inpatient DRG"
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1568.34","1176.25","AETNA [1001]","HB CH AETNA HMO / PPO","914.34","58.3","","2190.90","412.50","9264.59","16","697.13","1221.89","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1568.34","1176.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","909.64","58","","1903.20","1903.20","3826.66","1 through 10","697.13","1221.89","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1568.34","1176.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","980.21","62.5","","2186.25","2186.25","2186.25","32","697.13","1221.89","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1568.34","1176.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1144.89","73","","5556.60","5556.60","5556.60","1 through 10","697.13","1221.89","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1568.34","1176.25","WELLPOINT [1015]","HB CH WELLPOINT","1221.89","77.91","","1955.15","885.83","3150.40","26","697.13","1221.89","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1568.34","1176.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","930.03","59.3","","831.03","253.22","2394.88","18","784.17","1230.36","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1568.34","1176.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1230.36","78.45","","2481.69","1563.74","8149.28","1 through 10","784.17","1230.36","percent of total billed charges",""
"Fracture Of Femur,EXTREME","340","DRG","","","","","","","","inpatient","","","41868.94","","MASSHEALTH [3001]","HB NWH MEDICAID","15579.59","","Case rate ($16,784.55). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,214.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16827.71","16827.71","16827.71","1 through 10","5321.33","96029.08","case rate",""
"Fracture Of Femur,MODERATE","340","DRG","","","","","","","","inpatient","","","22192.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14944.55","","Standard inlier is a Case rate ($14,944.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,121.32) for the length of stay and the standard reimbursement.","14944.54","14944.54","14944.54","1 through 10","5321.33","96029.08","case rate",""
"Fracture Of Femur,MODERATE","340","DRG","","","","","","","","inpatient","","","22192.66","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13429.6855","","Fee schedule rate ($14,812.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13429.6855","13331.32","13331.32","1 through 10","5321.33","96029.08","case rate",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","31934.48","23950.86","MEDICARE [2001]","HB NWH MEDICARE","12344.36","","Case rate ($12,344.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,681.01, add-ons for qualifying new technology services are included. If operating cost exceeds $57,823.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,885.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,401.02. The transfer operating threshold is the transfer adjustment factor * $12,681.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.34. The transfer capital threshold is the transfer adjustment factor * $943.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13651.57","10220.17","13993.00","13","12097.47","14472.5515","other","Inpatient Replacement Plans DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","31934.48","23950.86","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12097.47","","Case rate ($12,344.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,681.01, add-ons for qualifying new technology services are included. If operating cost exceeds $57,823.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,885.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,401.02. The transfer operating threshold is the transfer adjustment factor * $12,681.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.34. The transfer capital threshold is the transfer adjustment factor * $943.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12195.07","12195.07","12195.07","1 through 10","12097.47","14472.5515","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","24011.37","18008.53","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7991.30","","Case rate ($7,758.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,970.13, add-ons for qualifying new technology services are included. If operating cost exceeds $53,112.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,534.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,165.65. The transfer operating threshold is the transfer adjustment factor * $7,970.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.90. The transfer capital threshold is the transfer adjustment factor * $592.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8041.65","8041.65","8041.65","1 through 10","7603.37","9192.31","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","24011.37","18008.53","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8530.71","","Case rate ($8,530.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,970.13, add-ons for qualifying new technology services are included. If operating cost exceeds $53,112.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,534.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,937.81. The transfer operating threshold is the transfer adjustment factor * $7,970.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.90. The transfer capital threshold is the transfer adjustment factor * $592.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7707.64","7707.64","7707.64","1 through 10","7603.37","9192.31","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","24011.37","18008.53","MEDICARE [2001]","HB NWH MEDICARE","8530.71","","Case rate ($8,530.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,970.13, add-ons for qualifying new technology services are included. If operating cost exceeds $53,112.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,534.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,937.81. The transfer operating threshold is the transfer adjustment factor * $7,970.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $592.90. The transfer capital threshold is the transfer adjustment factor * $592.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8530.57","6093.39","8545.91","41","7603.37","9192.31","other","Inpatient DRG"
"Fractures And Dislocations Except Femur, Pelvis And Back,MAJOR","342","DRG","","","","","","","","inpatient","","","32669.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10009.63","","Fee schedule rate ($10,009.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10009.63","10009.63","10009.63","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MAJOR","342","DRG","","","","","","","","inpatient","","","32669.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","21335.05","","Fee schedule rate ($21,335.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21335.05","21335.05","21335.05","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","22081.31","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16397.6922","","Fee schedule rate ($13,685.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16397.6922","13685.26","13685.26","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","22081.31","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8891.61","","Fee schedule rate ($13,685.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8891.61","13685.26","13685.26","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","22081.31","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17217.4929","","Fee schedule rate ($14,369.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17217.4929","14369.44","14369.44","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","22081.31","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9336.145","","Fee schedule rate ($14,369.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9336.145","14369.44","14369.44","1 through 10","4473.51","109616.7","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","22081.31","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5417.10","","Case rate ($5,836.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,266.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5851.08","5851.08","5851.08","1 through 10","4473.51","109616.7","case rate",""
"Fractures Of Femur Without McC","534","MS-DRG","","","","","","","","inpatient","","","19441.96","14581.47","MEDICARE [2001]","HB NWH MEDICARE","7679.07","","Case rate ($7,679.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,174.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,316.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,145.36. The transfer operating threshold is the transfer adjustment factor * $7,174.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.71. The transfer capital threshold is the transfer adjustment factor * $533.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","986.81","424.41","7768.96","1 through 10","6844.31","8049.646","other","Inpatient DRG"
"Fractures Of Femur Without McC","534","MS-DRG","","","","","","","","inpatient","","","19441.96","14581.47","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6844.31","","Case rate ($6,983.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,174.45, add-ons for qualifying new technology services are included. If operating cost exceeds $52,316.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,450.28. The transfer operating threshold is the transfer adjustment factor * $7,174.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.71. The transfer capital threshold is the transfer adjustment factor * $533.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33.17","33.17","33.17","1 through 10","6844.31","8049.646","other","Inpatient DRG"
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","30400.99","22800.74","MEDICARE [2001]","HB NWH MEDICARE","12212.60","","Case rate ($12,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,410.06, add-ons for qualifying new technology services are included. If operating cost exceeds $56,552.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,790.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,363.79. The transfer operating threshold is the transfer adjustment factor * $11,410.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.80. The transfer capital threshold is the transfer adjustment factor * $848.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12692.80","12692.63","12715.61","12","10885.02","13159.73","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","26830.95","20123.21","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7693.35","","Case rate ($7,693.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,187.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,330.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,476.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,158.66. The transfer operating threshold is the transfer adjustment factor * $7,187.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.70. The transfer capital threshold is the transfer adjustment factor * $534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6992.77","6992.77","6992.77","1 through 10","6857.04","8290.01","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","26830.95","20123.21","MEDICARE [2001]","HB NWH MEDICARE","7693.35","","Case rate ($7,693.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,187.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,330.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,476.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,158.66. The transfer operating threshold is the transfer adjustment factor * $7,187.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.70. The transfer capital threshold is the transfer adjustment factor * $534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7739.36","7739.26","7739.36","1 through 10","6857.04","8290.01","other","Inpatient DRG"
"Frenectomy","PX-75000033","CDM","41115","CPT","0761","RC","","","","both","","","1930.00","1447.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","156.52","1723.75","per diem",""
"Frenectomy","PX-75000033","CDM","41115","CPT","0761","RC","","","","outpatient","","","1930.00","1447.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1462.72","","Case rate ($1,462.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1057.55","1057.55","1057.55","1 through 10","965","1873.9","other","ASC "
"Frenectomy","PX-75000033","CDM","41115","CPT","0761","RC","","","","outpatient","","","1930.00","1447.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1151.19","","Case rate ($1,151.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","11656.88","11656.88","11656.88","1 through 10","965","1873.9","other","Multiple Surgery"
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","AETNA [1001]","HB CH AETNA HMO / PPO","2271.95","58.3","","464.71","67.87","1012.10","221","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2271.95","58.3","","293.04","293.04","293.04","11","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2065.41","53","","983.89","983.89","983.89","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2260.26","58","","677.18","677.18","677.18","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2435.63","62.5","","46.58","46.58","46.58","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2844.81","73","","747.15","747.15","747.15","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","44.45","","1141.67","481.21","1141.67","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","44.45","","76.54","76.54","76.54","1 through 10","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3897.00","2922.75","WELLPOINT [1015]","HB CH WELLPOINT","3036.15","77.91","","273.64","94.28","1367.51","138","1732.22","3036.15","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3897.00","2922.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2310.92","59.3","","720.78","230.14","2010.94","427","1948.5","3057.2","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3897.00","2922.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2310.92","59.3","","344.45","344.45","344.45","1 through 10","1948.5","3057.2","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3897.00","2922.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3057.20","78.45","","1120.13","1120.13","1120.13","1 through 10","1948.5","3057.2","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3897.00","2922.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3057.20","78.45","","456.17","105.33","1284.66","242","1948.5","3057.2","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3067.37","49.07","","1803.97","1803.97","1803.97","1 through 10","2500.4","4903.91","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3131.75","50.1","","1806.52","1806.52","3689.58","1 through 10","2500.4","4903.91","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3706.84","59.3","","3093.52","3093.52","3093.52","1 through 10","2500.4","4903.91","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4903.91","78.45","","3885.52","2400.10","3885.52","1 through 10","2500.4","4903.91","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1258.00","943.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.03","386.03","386.03","1 through 10","405.83","1085.77","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1258.00","943.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","384.46","384.46","384.46","1 through 10","405.83","1085.77","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","384.47","384.47","384.47","1 through 10","405.83","1085.77","other","OPPS APC"
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","AETNA [1001]","HB CH AETNA HMO / PPO","34980.00","58.3","","2190.90","412.50","9264.59","16","26670","46746","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","34800.00","58","","1903.20","1903.20","3826.66","1 through 10","26670","46746","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37500.00","62.5","","2186.25","2186.25","2186.25","32","26670","46746","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43800.00","73","","5556.60","5556.60","5556.60","1 through 10","26670","46746","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","WELLPOINT [1015]","HB CH WELLPOINT","46746.00","77.91","","1955.15","885.83","3150.40","26","26670","46746","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35580.00","59.3","","831.03","253.22","2394.88","18","30000","47070","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47070.00","78.45","","2481.69","1563.74","8149.28","1 through 10","30000","47070","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","outpatient","","","67.00","50.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.73","59.3","","38.09","38.09","38.09","1 through 10","5.98","52.56","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","outpatient","","","67.00","50.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","52.56","78.45","","49.97","49.97","49.97","1 through 10","5.98","52.56","percent of total billed charges",""
"Gadoteridol Vl 279.3mg/Ml 1ml","PX-25000082","CDM","A9579","HCPCS","0255","RC","","","","both","","","50.25","37.69","AETNA [1001]","HB CH AETNA HMO / PPO","29.30","58.3","","4.89","0.46","4.89","1 through 10","3.76","36.68","percent of total billed charges",""
"Gadoteridol Vl 279.3mg/Ml 1ml","PX-25000082","CDM","A9579","HCPCS","0255","RC","","","","outpatient","","","50.25","37.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","39.42","78.45","","3.18","3.18","3.23","1 through 10","22.34","39.42","percent of total billed charges",""
"Galectin-3","PX-30001385","CDM","82777","CPT","0301","RC","","","","both","","","157.00","117.75","AETNA [1001]","HB CH AETNA HMO / PPO","91.53","58.3","","86.75","86.75","86.75","1 through 10","43.37","234.97","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","47","16.13","129.2","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","136.00","102.00","TRICARE [160005]","HB NWH TRICARE","129.20","95","","19.83","19.83","19.83","1 through 10","16.13","129.2","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.45","44.45","","101.48","60.14","101.48","1 through 10","16.13","129.2","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","46","16.98","106.69","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","60.14","101.48","29","16.98","106.69","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","AETNA [1001]","HB CH AETNA HMO / PPO","37.90","58.3","","35.72","35.72","35.72","311","9.11","61.75","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","47.45","73","","45.99","45.99","45.99","1 through 10","9.11","61.75","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","47.45","73","","137.97","62.78","137.97","1 through 10","9.11","61.75","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","TRICARE [160005]","HB NWH TRICARE","61.75","95","","11.21","10.65","33.63","1 through 10","9.11","61.75","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.89","44.45","","48.43","28.70","48.43","1 through 10","9.11","61.75","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","65.00","48.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.55","59.3","","36.92","36.92","36.92","265","7.66","50.99","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.99","78.45","","48.43","28.70","48.44","200","7.66","50.99","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","2175.00","1631.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","2068.43","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","2175.00","1631.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1089.68","50.1","","2255.00","204.62","2255.00","1 through 10","567.68","1706.29","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1706.29","78.45","","1733.64","1733.64","1733.64","1 through 10","567.68","1706.29","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","175","11.3","132.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","98.55","98.55","98.55","1 through 10","11.3","132.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","95.63","95.63","95.63","1 through 10","11.3","132.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","TRICARE [160005]","HB NWH TRICARE","132.05","95","","13.89","13.89","26.39","1 through 10","11.3","132.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","61.51","103.79","1 through 10","11.3","132.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","79.11","177","11.81","109.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","103.79","61.51","103.79","159","11.81","109.05","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","AETNA [1001]","HB CH AETNA HMO / PPO","1108.87","58.3","","1048.38","1048.38","1048.38","1 through 10","453.34","1388.46","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","442.95","469.56","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","59","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","469.66","469.16","470.46","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.66","234.03","472.66","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1127.89","59.3","","1083.51","1083.51","1083.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1492.12","78.45","","1849.00","813.23","2287.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"Gastric Fundoplication,MINOR","232","DRG","","","","","","","","inpatient","","","45437.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29467.75","","Standard inlier is a Case rate ($29,467.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,790, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,182.82) for the length of stay and the standard reimbursement.","29467.74","29467.74","29467.74","1 through 10","9905.46","29467.75","case rate",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","both","","","148.00","111.00","AETNA [1001]","HB CH AETNA HMO / PPO","86.28","58.3","","81.65","81.65","81.65","1 through 10","17.28","140.6","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","both","","","148.00","111.00","TRICARE [160005]","HB NWH TRICARE","140.60","95","","21.24","21.24","21.24","1 through 10","17.28","140.6","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","outpatient","","","148.00","111.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.11","78.45","","110.71","110.71","110.71","1 through 10","18.2","116.11","percent of total billed charges",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8751.62","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8859.95","8859.95","8859.95","1 through 10","8326.79","10066.89","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8496.72","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8501.88","8501.88","8501.88","1 through 10","8326.79","10066.89","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","8496.72","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8413.23","8413.23","8413.23","1 through 10","8326.79","10066.89","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","HUMANA [1012]","HB NWH MEDICARE","8496.72","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8406.29","8406.29","8406.29","1 through 10","8326.79","10066.89","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","MEDICARE [2001]","HB NWH MEDICARE","8496.72","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9409.60","6501.48","9426.52","47","8326.79","10066.89","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8326.79","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8409.74","8407.74","9508.00","1 through 10","8326.79","10066.89","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","24494.20","18370.65","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8326.79","","Case rate ($8,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,728.43, add-ons for qualifying new technology services are included. If operating cost exceeds $53,870.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,591.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,847.40. The transfer operating threshold is the transfer adjustment factor * $8,728.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.31. The transfer capital threshold is the transfer adjustment factor * $649.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8577.85","8577.85","8577.85","1 through 10","8326.79","10066.89","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41548.64","31161.48","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","17413.88","","Case rate ($17,413.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,269.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,152.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,203.60. The transfer operating threshold is the transfer adjustment factor * $16,269.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.30. The transfer capital threshold is the transfer adjustment factor * $1,210.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10453.16","10453.16","10453.16","1 through 10","15520.89","18764.42","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41548.64","31161.48","FALLON HEALTH [1008]","HB NWH MEDICARE","17413.88","","Case rate ($17,413.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,269.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,152.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,203.60. The transfer operating threshold is the transfer adjustment factor * $16,269.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.30. The transfer capital threshold is the transfer adjustment factor * $1,210.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15814.48","15814.48","15814.48","1 through 10","15520.89","18764.42","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41548.64","31161.48","MEDICARE [2001]","HB NWH MEDICARE","17413.88","","Case rate ($17,413.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,269.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,152.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,203.60. The transfer operating threshold is the transfer adjustment factor * $16,269.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.30. The transfer capital threshold is the transfer adjustment factor * $1,210.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17353.20","1142.68","17384.40","47","15520.89","18764.42","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41548.64","31161.48","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15520.89","","Case rate ($15,837.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,269.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,152.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,627.36. The transfer operating threshold is the transfer adjustment factor * $16,269.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.30. The transfer capital threshold is the transfer adjustment factor * $1,210.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15502.89","15502.89","15531.13","1 through 10","15520.89","18764.42","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41548.64","31161.48","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15520.89","","Case rate ($15,837.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,269.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,152.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,627.36. The transfer operating threshold is the transfer adjustment factor * $16,269.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.30. The transfer capital threshold is the transfer adjustment factor * $1,210.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15498.19","10351.59","17791.86","1 through 10","15520.89","18764.42","other","Inpatient DRG"
"Gastrointestinal Hemorrhage Without Cc/McC","379","MS-DRG","","","","","","","","inpatient","","","16623.23","12467.42","MEDICARE [2001]","HB NWH MEDICARE","6005.32","","Case rate ($6,005.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,610.69, add-ons for qualifying new technology services are included. If operating cost exceeds $50,752.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,359.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,587.94. The transfer operating threshold is the transfer adjustment factor * $5,610.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.38. The transfer capital threshold is the transfer adjustment factor * $417.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","701.03","701.03","6087.69","1 through 10","5352.51","6296.3263","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","17239.27","12929.45","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7048.06","","Case rate ($6,842.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,029.39, add-ons for qualifying new technology services are included. If operating cost exceeds $52,171.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,464.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,319.85. The transfer operating threshold is the transfer adjustment factor * $7,029.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.92. The transfer capital threshold is the transfer adjustment factor * $522.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7194.21","7194.21","7194.21","1 through 10","6705.92","8107.3","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","17239.27","12929.45","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7523.81","","Case rate ($7,523.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,029.39, add-ons for qualifying new technology services are included. If operating cost exceeds $52,171.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,464.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,000.88. The transfer operating threshold is the transfer adjustment factor * $7,029.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.92. The transfer capital threshold is the transfer adjustment factor * $522.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4608.55","4608.55","4608.55","1 through 10","6705.92","8107.3","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","17239.27","12929.45","MEDICARE [2001]","HB NWH MEDICARE","7523.81","","Case rate ($7,523.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,029.39, add-ons for qualifying new technology services are included. If operating cost exceeds $52,171.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,464.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,000.88. The transfer operating threshold is the transfer adjustment factor * $7,029.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.92. The transfer capital threshold is the transfer adjustment factor * $522.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7650.60","7650.50","7664.36","36","6705.92","8107.3","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","17239.27","12929.45","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6705.92","","Case rate ($6,842.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,029.39, add-ons for qualifying new technology services are included. If operating cost exceeds $52,171.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,464.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,319.85. The transfer operating threshold is the transfer adjustment factor * $7,029.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.92. The transfer capital threshold is the transfer adjustment factor * $522.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6838.85","6838.85","6850.06","1 through 10","6705.92","8107.3","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","17239.27","12929.45","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6705.92","","Case rate ($6,842.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,029.39, add-ons for qualifying new technology services are included. If operating cost exceeds $52,171.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,464.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,319.85. The transfer operating threshold is the transfer adjustment factor * $7,029.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.92. The transfer capital threshold is the transfer adjustment factor * $522.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6872.28","6872.28","6872.28","1 through 10","6705.92","8107.3","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","26446.42","19834.81","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13178.73","","Case rate ($12,794.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,143.82, add-ons for qualifying new technology services are included. If operating cost exceeds $58,286.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,919.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,817.11. The transfer operating threshold is the transfer adjustment factor * $13,143.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $977.77. The transfer capital threshold is the transfer adjustment factor * $977.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13159.76","13159.76","13159.76","1 through 10","12538.98","15159.35","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","26446.42","19834.81","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14068.29","","Case rate ($14,068.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,143.82, add-ons for qualifying new technology services are included. If operating cost exceeds $58,286.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,919.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,090.52. The transfer operating threshold is the transfer adjustment factor * $13,143.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $977.77. The transfer capital threshold is the transfer adjustment factor * $977.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13829.32","13829.32","13829.32","1 through 10","12538.98","15159.35","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","26446.42","19834.81","MEDICARE [2001]","HB NWH MEDICARE","14068.29","","Case rate ($14,068.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,143.82, add-ons for qualifying new technology services are included. If operating cost exceeds $58,286.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,919.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,090.52. The transfer operating threshold is the transfer adjustment factor * $13,143.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $977.77. The transfer capital threshold is the transfer adjustment factor * $977.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14028.97","12470.37","14054.19","33","12538.98","15159.35","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","26446.42","19834.81","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12538.98","","Case rate ($12,794.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,143.82, add-ons for qualifying new technology services are included. If operating cost exceeds $58,286.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,919.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,817.11. The transfer operating threshold is the transfer adjustment factor * $13,143.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $977.77. The transfer capital threshold is the transfer adjustment factor * $977.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12535.31","12535.31","12535.31","1 through 10","12538.98","15159.35","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","15484.96","11613.72","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","4854.57","","Case rate ($4,713.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,841.71, add-ons for qualifying new technology services are included. If operating cost exceeds $49,983.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,302.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,353.00. The transfer operating threshold is the transfer adjustment factor * $4,841.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.18. The transfer capital threshold is the transfer adjustment factor * $360.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4911.39","4911.39","4911.39","1 through 10","4618.91","5411.2608","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","15484.96","11613.72","HUMANA [1012]","HB NWH MEDICARE","4713.17","","Case rate ($4,713.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,841.71, add-ons for qualifying new technology services are included. If operating cost exceeds $49,983.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,302.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,353.00. The transfer operating threshold is the transfer adjustment factor * $4,841.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.18. The transfer capital threshold is the transfer adjustment factor * $360.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4680.25","4680.25","4680.25","1 through 10","4618.91","5411.2608","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","15484.96","11613.72","MEDICARE [2001]","HB NWH MEDICARE","4713.17","","Case rate ($4,713.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,841.71, add-ons for qualifying new technology services are included. If operating cost exceeds $49,983.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,302.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,353.00. The transfer operating threshold is the transfer adjustment factor * $4,841.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.18. The transfer capital threshold is the transfer adjustment factor * $360.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5231.95","5222.57","5231.95","19","4618.91","5411.2608","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","15484.96","11613.72","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","4618.91","","Case rate ($4,713.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,841.71, add-ons for qualifying new technology services are included. If operating cost exceeds $49,983.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,302.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,353.00. The transfer operating threshold is the transfer adjustment factor * $4,841.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.18. The transfer capital threshold is the transfer adjustment factor * $360.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4676.29","4676.29","4676.29","1 through 10","4618.91","5411.2608","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","TRIS-DRG","","","","","","","","inpatient","","","9883.18","","TRICARE [160005]","HB NWH TRICARE","3444.72","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($4,829.69). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $2,414.85, and the first day is paid a rate of $4,829.69. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $2,414.85, and the first day is paid a rate of $4,829.69. The transfer payment is capped at $4,355.00. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,651.14 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,199.73), capped at $4,355.00. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $2,414.85, and the first day is paid a rate of $4,829.69. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $2,414.85, and the first day is paid a rate of $4,829.69. The transfer payment is capped at $4,355.00. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,651.14 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","5335.63","5335.63","5335.63","1 through 10","3444.72","3444.72","other","Inpatient DRGs"
"Gastrointestinal Vascular Insufficiency,MAJOR","246","DRG","","","","","","","","inpatient","","","47633.73","","MASSHEALTH [3001]","HB NWH MEDICAID","8823.63","","Case rate ($9,506.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,936.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9530.52","9530.52","9530.52","1 through 10","5888.9","90537.93","case rate",""
"Gastrointestinal Vascular Insufficiency,MODERATE","246","DRG","","","","","","","","inpatient","","","20218.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19276.49","","Standard inlier is a Case rate ($19,276.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,058, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,736.22) for the length of stay and the standard reimbursement.","18400.28","18400.28","18400.28","1 through 10","5888.9","90537.93","case rate",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0300","RC","","","","inpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.39","70.6","","181.78","181.78","181.78","1 through 10","120.55","198.39","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB CH AETNA HMO / PPO","163.82","58.3","","226.23","226.23","226.23","395","148.93","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","205.13","73","","291.27","291.27","291.27","1 through 10","148.93","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","205.13","73","","282.51","226.23","329.80","1 through 10","148.93","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","TRICARE [160005]","HB NWH TRICARE","266.95","95","","74.98","72.94","76.78","1 through 10","148.93","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","WELLPOINT [1015]","HB CH WELLPOINT","218.93","77.91","","314.25","314.25","326.85","119","148.93","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.63","59.3","","233.81","233.81","233.81","394","16.94","246.25","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.90","44.45","","306.75","181.78","306.76","1 through 10","16.94","246.25","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.44","78.45","","306.75","181.78","306.75","290","16.94","246.25","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","both","","","36450.00","27337.50","AETNA [1001]","HB CH AETNA HMO / PPO","21250.35","58.3","","41334.30","41334.30","41334.30","1 through 10","19318.5","28398.2","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","36450.00","27337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","21614.85","59.3","","21359.70","21359.70","21359.70","1 through 10","16202.03","28595.03","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","36450.00","27337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28595.03","78.45","","28022.76","16606.62","28022.76","1 through 10","16202.03","28595.03","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","216.00","162.00","AETNA [1001]","HB CH AETNA HMO / PPO","125.93","58.3","","122.47","122.47","244.94","1 through 10","114.48","205.42","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","216.00","162.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","136.94","63.4","","233.31","116.66","349.97","1 through 10","114.48","205.42","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","135.00","62.5","","199.61","199.60","362.34","1 through 10","114.48","205.42","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","216.00","162.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","124.63","57.7","","317.64","105.88","317.64","1 through 10","28.88","169.45","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","216.00","162.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","130.68","60.5","","223.01","58.33","334.51","1 through 10","28.88","169.45","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","130.68","60.5","","38.89","38.89","38.89","1 through 10","28.88","169.45","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","169.45","78.45","","166.06","166.06","332.12","1 through 10","28.88","169.45","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","3342.00","2506.50","MEDICARE [2001]","HB NWH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1433.72","2603.75","other","OPPS APC"
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","29","7.06","57","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","60.00","45.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","42.34","42.34","42.34","1 through 10","7.06","57","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","60.00","45.00","TRICARE [160005]","HB NWH TRICARE","57.00","95","","66.68","8.68","66.68","1 through 10","7.06","57","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","44.59","44.59","44.59","1 through 10","7.06","57","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","29","7.42","47.07","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","17","7.42","47.07","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE LASER 8 DEGREE POSTERIOR AUGMENT CEMENTED RIGHT LARGE","SUP-ITM-10328793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE LASER XL 8DEGREES POSTERIOR AUG RIGHT EQUINOXE","SUP-ITM-10325261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"GLENOID CAGE MEDIUM LASER 8 POST AUG LEFT","SUP-ITM-10327977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"GLENOID COMPONENT 15DEG LG CORTILOC LT","SUP-ITM-10205056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","AETNA [1001]","HB CH AETNA HMO / PPO","2325.22","58.3","","1530.90","1160.93","1884.08","89","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.84","53","","5253.92","5253.92","5253.92","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2313.25","58","","12181.47","12181.47","12181.47","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2492.73","62.5","","1350.68","1350.68","1350.68","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.83","44.45","","1910.74","891.94","1910.74","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","WELLPOINT [1015]","HB CH WELLPOINT","3107.34","77.91","","1829.79","1561.50","2617.12","88","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1359.46","1201.30","1689.00","61","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 38 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.88","78.45","","1910.74","1019.06","2344.84","74","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","AETNA [1001]","HB CH AETNA HMO / PPO","2325.22","58.3","","1530.90","1160.93","1884.08","89","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.84","53","","5253.92","5253.92","5253.92","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2313.25","58","","12181.47","12181.47","12181.47","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2492.73","62.5","","1350.68","1350.68","1350.68","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.83","44.45","","1910.74","891.94","1910.74","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","WELLPOINT [1015]","HB CH WELLPOINT","3107.34","77.91","","1829.79","1561.50","2617.12","88","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1359.46","1201.30","1689.00","61","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 42 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.88","78.45","","1910.74","1019.06","2344.84","74","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","AETNA [1001]","HB CH AETNA HMO / PPO","2325.22","58.3","","1530.90","1160.93","1884.08","89","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.84","53","","5253.92","5253.92","5253.92","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2313.25","58","","12181.47","12181.47","12181.47","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2492.73","62.5","","1350.68","1350.68","1350.68","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.83","44.45","","1910.74","891.94","1910.74","1 through 10","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3988.37","2991.28","WELLPOINT [1015]","HB CH WELLPOINT","3107.34","77.91","","1829.79","1561.50","2617.12","88","1772.83","3107.34","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1359.46","1201.30","1689.00","61","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2365.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1994.19","3128.88","percent of total billed charges",""
"GLENOID PEGGED SIZE 46 E-PLUS ALTIVATE ANATOMIC ALL-POLY","SUP-ITM-10207486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3988.37","2991.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.88","78.45","","1910.74","1019.06","2344.84","74","1994.19","3128.88","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"GLENOSPHERE 32 +8MM INHANCE SHOULDER SYSTEM","SUP-ITM-10319598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1530.90","1160.93","1884.08","89","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","5253.92","5253.92","5253.92","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","12181.47","12181.47","12181.47","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1910.74","891.94","1910.74","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","1829.79","1561.50","2617.12","88","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1359.46","1201.30","1689.00","61","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1910.74","1019.06","2344.84","74","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1530.90","1160.93","1884.08","89","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","5253.92","5253.92","5253.92","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","12181.47","12181.47","12181.47","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1910.74","891.94","1910.74","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","1829.79","1561.50","2617.12","88","1600.2","2804.76","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1359.46","1201.30","1689.00","61","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1910.74","1019.06","2344.84","74","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","AETNA [1001]","HB CH AETNA HMO / PPO","2218.43","58.3","","1530.90","1160.93","1884.08","89","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2016.76","53","","5253.92","5253.92","5253.92","1 through 10","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2207.02","58","","12181.47","12181.47","12181.47","1 through 10","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2378.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1691.41","44.45","","1910.74","891.94","1910.74","1 through 10","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","WELLPOINT [1015]","HB CH WELLPOINT","2964.63","77.91","","1829.79","1561.50","2617.12","88","1691.41","2964.63","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1359.46","1201.30","1689.00","61","1902.6","2985.18","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1718.92","1718.92","1718.92","1 through 10","1902.6","2985.18","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY STANDARD","SUP-ITM-10123271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2985.18","78.45","","1910.74","1019.06","2344.84","74","1902.6","2985.18","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","1 through 10","17.87","76.88","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","71.63","60.14","71.63","1 through 10","17.87","76.88","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","outpatient","","","619.00","464.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","310.12","50.1","","153.61","153.61","153.61","1 through 10","247.6","485.61","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","28","3.85","39.9","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","TRICARE [160005]","HB NWH TRICARE","39.90","95","","4.50","4.50","4.50","1 through 10","3.85","39.9","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.67","44.45","","31.52","31.52","31.52","1 through 10","3.85","39.9","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.67","44.45","","18.68","18.68","18.68","1 through 10","3.85","39.9","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","24.03","12","4.05","32.95","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","18.68","31.52","31","4.05","32.95","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","27.00","20.25","AETNA [1001]","HB CH AETNA HMO / PPO","15.74","58.3","","14.74","14.74","14.74","12","3.21","25.65","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","27.00","20.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","16.01","59.3","","15.24","15.24","41.24","18","2.42","21.18","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","27.00","20.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","21.18","78.45","","19.99","11.85","26.00","1 through 10","2.42","21.18","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","36.00","27.00","AETNA [1001]","HB CH AETNA HMO / PPO","20.99","58.3","","19.85","19.85","19.85","1 through 10","3.85","34.2","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","36.00","27.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.24","78.45","","26.91","15.95","26.91","1 through 10","4.05","28.24","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","39.00","29.25","AETNA [1001]","HB CH AETNA HMO / PPO","22.74","58.3","","21.55","21.55","21.55","159","4.66","37.05","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","39.00","29.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","28.47","73","","21.55","6.12","21.55","1 through 10","4.66","37.05","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","39.00","29.25","TRICARE [160005]","HB NWH TRICARE","37.05","95","","5.72","5.72","5.72","1 through 10","4.66","37.05","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","23.13","59.3","","22.27","22.27","22.27","129","4.89","30.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.34","44.45","","29.21","29.21","29.21","1 through 10","4.89","30.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","30.60","78.45","","29.21","17.31","29.21","137","4.89","30.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.34","44.45","","17.31","17.31","17.31","1 through 10","4.89","30.6","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","58","12.61","100.7","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","106.00","79.50","TRICARE [160005]","HB NWH TRICARE","100.70","95","","103.00","15.51","103.00","1 through 10","12.61","100.7","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","33","13.27","83.16","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","46.93","79.19","34","13.27","83.16","percent of total billed charges",""
"Glucose Tolerance Add Specimen","PX-30000467","CDM","82952","CPT","0301","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","45","3.84","32.3","percent of total billed charges",""
"Glucose Tolerance Add Specimen","PX-30000467","CDM","82952","CPT","0301","RC","","","","both","","","34.00","25.50","TRICARE [160005]","HB NWH TRICARE","32.30","95","","33.00","33.00","33.00","1 through 10","3.84","32.3","percent of total billed charges",""
"Glucose Tolerance Add Specimen","PX-30000467","CDM","82952","CPT","0301","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","19.34","27","2.97","26.67","percent of total billed charges",""
"Glucose Tolerance Add Specimen","PX-30000467","CDM","82952","CPT","0301","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","15.03","25.37","30","2.97","26.67","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","16.42","114.95","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","15.54","95.03","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","90.72","90.72","1 through 10","15.54","95.03","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","3845.32","2883.99","AETNA [1001]","HB CH AETNA HMO / PPO","2241.82","58.3","","2190.90","412.50","9264.59","16","1709.24","2995.89","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","3845.32","2883.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2230.29","58","","1903.20","1903.20","3826.66","1 through 10","1709.24","2995.89","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","3845.32","2883.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2403.33","62.5","","2186.25","2186.25","2186.25","32","1709.24","2995.89","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","3845.32","2883.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2807.08","73","","5556.60","5556.60","5556.60","1 through 10","1709.24","2995.89","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","3845.32","2883.99","WELLPOINT [1015]","HB CH WELLPOINT","2995.89","77.91","","1955.15","885.83","3150.40","26","1709.24","2995.89","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3845.32","2883.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","2280.27","59.3","","831.03","253.22","2394.88","18","1922.66","3016.65","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3845.32","2883.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3016.65","78.45","","2481.69","1563.74","8149.28","1 through 10","1922.66","3016.65","percent of total billed charges",""
"GRAFT ALLO 1IN MATRIX DURAL DURAGEN COLLAGEN SUTURABLE CA/1EA","SUP-ITM-10024786","CDM","C1763","HCPCS","0278","RC","","","","both","","","723.00","542.25","AETNA [1001]","HB CH AETNA HMO / PPO","421.51","58.3","","416.75","416.75","416.75","1 through 10","321.37","563.29","percent of total billed charges",""
"GRAFT ALLO 1IN MATRIX DURAL DURAGEN COLLAGEN SUTURABLE CA/1EA","SUP-ITM-10024786","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","723.00","542.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.74","59.3","","7893.60","423.68","7893.60","1 through 10","361.5","567.19","percent of total billed charges",""
"GRAFT ALLO 1IN MATRIX DURAL DURAGEN COLLAGEN SUTURABLE CA/1EA","SUP-ITM-10024786","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","723.00","542.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.19","78.45","","555.84","329.40","555.84","1 through 10","361.5","567.19","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","both","","","12114.00","9085.50","AETNA [1001]","HB CH AETNA HMO / PPO","7062.46","58.3","","2190.90","412.50","9264.59","16","5384.67","9438.02","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","both","","","12114.00","9085.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7026.12","58","","1903.20","1903.20","3826.66","1 through 10","5384.67","9438.02","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","both","","","12114.00","9085.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7571.25","62.5","","2186.25","2186.25","2186.25","32","5384.67","9438.02","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","both","","","12114.00","9085.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8843.22","73","","5556.60","5556.60","5556.60","1 through 10","5384.67","9438.02","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","both","","","12114.00","9085.50","WELLPOINT [1015]","HB CH WELLPOINT","9438.02","77.91","","1955.15","885.83","3150.40","26","5384.67","9438.02","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12114.00","9085.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7183.60","59.3","","831.03","253.22","2394.88","18","6057","9503.43","percent of total billed charges",""
"GRAFT ALLO 21 TO 30CMX3MM VEIN SAPHENOUS CRYOPRESERVED","SUP-ITM-10013883","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12114.00","9085.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9503.43","78.45","","2481.69","1563.74","8149.28","1 through 10","6057","9503.43","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","both","","","4374.70","3281.02","AETNA [1001]","HB CH AETNA HMO / PPO","2550.45","58.3","","2190.90","412.50","9264.59","16","1944.55","3408.33","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","both","","","4374.70","3281.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.33","58","","1903.20","1903.20","3826.66","1 through 10","1944.55","3408.33","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","both","","","4374.70","3281.02","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.19","62.5","","2186.25","2186.25","2186.25","32","1944.55","3408.33","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","both","","","4374.70","3281.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.53","73","","5556.60","5556.60","5556.60","1 through 10","1944.55","3408.33","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","both","","","4374.70","3281.02","WELLPOINT [1015]","HB CH WELLPOINT","3408.33","77.91","","1955.15","885.83","3150.40","26","1944.55","3408.33","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4374.70","3281.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.20","59.3","","831.03","253.22","2394.88","18","2187.35","3431.95","percent of total billed charges",""
"GRAFT ALLO TISSUE 10 20MMX19.5 38CM ACHILLES TENDON CALCANEUS FROZEN","SUP-ITM-10010685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4374.70","3281.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3431.95","78.45","","2481.69","1563.74","8149.28","1 through 10","2187.35","3431.95","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","both","","","3773.30","2829.97","AETNA [1001]","HB CH AETNA HMO / PPO","2199.83","58.3","","2190.90","412.50","9264.59","16","1677.23","2939.78","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","both","","","3773.30","2829.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2188.51","58","","1903.20","1903.20","3826.66","1 through 10","1677.23","2939.78","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","both","","","3773.30","2829.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2358.31","62.5","","2186.25","2186.25","2186.25","32","1677.23","2939.78","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","both","","","3773.30","2829.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2754.51","73","","5556.60","5556.60","5556.60","1 through 10","1677.23","2939.78","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","both","","","3773.30","2829.97","WELLPOINT [1015]","HB CH WELLPOINT","2939.78","77.91","","1955.15","885.83","3150.40","26","1677.23","2939.78","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3773.30","2829.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","2237.57","59.3","","831.03","253.22","2394.88","18","1886.65","2960.15","percent of total billed charges",""
"GRAFT ALLO TISSUE 6.0 12MMX20 38CM ANTERIOR TIBIALIS FROZEN FOLD","SUP-ITM-10010696","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3773.30","2829.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2960.15","78.45","","2481.69","1563.74","8149.28","1 through 10","1886.65","2960.15","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","AETNA [1001]","HB CH AETNA HMO / PPO","2397.59","58.3","","464.71","67.87","1012.10","221","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2397.59","58.3","","293.04","293.04","293.04","11","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2179.63","53","","983.89","983.89","983.89","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2385.25","58","","677.18","677.18","677.18","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2570.31","62.5","","46.58","46.58","46.58","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3002.13","73","","747.15","747.15","747.15","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.01","44.45","","1141.67","481.21","1141.67","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.01","44.45","","76.54","76.54","76.54","1 through 10","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","WELLPOINT [1015]","HB CH WELLPOINT","3204.05","77.91","","273.64","94.28","1367.51","138","1828.01","3204.05","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2438.71","59.3","","720.78","230.14","2010.94","427","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2438.71","59.3","","344.45","344.45","344.45","1 through 10","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3226.26","78.45","","1120.13","1120.13","1120.13","1 through 10","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3226.26","78.45","","456.17","105.33","1284.66","242","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","2676.90","2007.67","AETNA [1001]","HB CH AETNA HMO / PPO","1560.63","58.3","","2190.90","412.50","9264.59","16","1189.88","2085.57","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","2676.90","2007.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1552.60","58","","1903.20","1903.20","3826.66","1 through 10","1189.88","2085.57","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","2676.90","2007.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1673.06","62.5","","2186.25","2186.25","2186.25","32","1189.88","2085.57","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","2676.90","2007.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1954.14","73","","5556.60","5556.60","5556.60","1 through 10","1189.88","2085.57","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","2676.90","2007.67","WELLPOINT [1015]","HB CH WELLPOINT","2085.57","77.91","","1955.15","885.83","3150.40","26","1189.88","2085.57","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2676.90","2007.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1587.40","59.3","","831.03","253.22","2394.88","18","1338.45","2100.03","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2676.90","2007.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2100.03","78.45","","2481.69","1563.74","8149.28","1 through 10","1338.45","2100.03","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","AETNA [1001]","HB CH AETNA HMO / PPO","281.38","58.3","","2190.90","412.50","9264.59","16","214.53","376.02","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","279.93","58","","1903.20","1903.20","3826.66","1 through 10","214.53","376.02","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","301.65","62.5","","2186.25","2186.25","2186.25","32","214.53","376.02","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","352.33","73","","5556.60","5556.60","5556.60","1 through 10","214.53","376.02","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","WELLPOINT [1015]","HB CH WELLPOINT","376.02","77.91","","1955.15","885.83","3150.40","26","214.53","376.02","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","482.64","361.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","286.21","59.3","","831.03","253.22","2394.88","18","241.32","378.63","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","482.64","361.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","378.63","78.45","","2481.69","1563.74","8149.28","1 through 10","241.32","378.63","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","AETNA [1001]","HB CH AETNA HMO / PPO","210.68","58.3","","2190.90","412.50","9264.59","16","160.63","281.55","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","209.60","58","","1903.20","1903.20","3826.66","1 through 10","160.63","281.55","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.86","62.5","","2186.25","2186.25","2186.25","32","160.63","281.55","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","263.81","73","","5556.60","5556.60","5556.60","1 through 10","160.63","281.55","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","WELLPOINT [1015]","HB CH WELLPOINT","281.55","77.91","","1955.15","885.83","3150.40","26","160.63","281.55","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.38","271.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.30","59.3","","831.03","253.22","2394.88","18","180.69","283.5","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.38","271.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.50","78.45","","2481.69","1563.74","8149.28","1 through 10","180.69","283.5","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","AETNA [1001]","HB CH AETNA HMO / PPO","428.47","58.3","","2190.90","412.50","9264.59","16","326.68","572.59","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.27","58","","1903.20","1903.20","3826.66","1 through 10","326.68","572.59","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","459.34","62.5","","2186.25","2186.25","2186.25","32","326.68","572.59","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","536.51","73","","5556.60","5556.60","5556.60","1 through 10","326.68","572.59","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","WELLPOINT [1015]","HB CH WELLPOINT","572.59","77.91","","1955.15","885.83","3150.40","26","326.68","572.59","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","734.94","551.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.82","59.3","","831.03","253.22","2394.88","18","367.47","576.56","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","734.94","551.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.56","78.45","","2481.69","1563.74","8149.28","1 through 10","367.47","576.56","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","both","","","723.99","542.99","AETNA [1001]","HB CH AETNA HMO / PPO","422.09","58.3","","2190.90","412.50","9264.59","16","321.81","564.06","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","both","","","723.99","542.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","419.91","58","","1903.20","1903.20","3826.66","1 through 10","321.81","564.06","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","both","","","723.99","542.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","452.49","62.5","","2186.25","2186.25","2186.25","32","321.81","564.06","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","both","","","723.99","542.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","528.51","73","","5556.60","5556.60","5556.60","1 through 10","321.81","564.06","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","both","","","723.99","542.99","WELLPOINT [1015]","HB CH WELLPOINT","564.06","77.91","","1955.15","885.83","3150.40","26","321.81","564.06","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","723.99","542.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","429.33","59.3","","831.03","253.22","2394.88","18","362","567.97","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CORTICAL CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","723.99","542.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.97","78.45","","2481.69","1563.74","8149.28","1 through 10","362","567.97","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","4548.70","3411.52","AETNA [1001]","HB CH AETNA HMO / PPO","2651.89","58.3","","2190.90","412.50","9264.59","16","2021.9","3543.89","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","4548.70","3411.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2638.25","58","","1903.20","1903.20","3826.66","1 through 10","2021.9","3543.89","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","4548.70","3411.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2842.94","62.5","","2186.25","2186.25","2186.25","32","2021.9","3543.89","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","4548.70","3411.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3320.55","73","","5556.60","5556.60","5556.60","1 through 10","2021.9","3543.89","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","4548.70","3411.52","WELLPOINT [1015]","HB CH WELLPOINT","3543.89","77.91","","1955.15","885.83","3150.40","26","2021.9","3543.89","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4548.70","3411.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","2697.38","59.3","","831.03","253.22","2394.88","18","2274.35","3568.46","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4548.70","3411.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3568.46","78.45","","2481.69","1563.74","8149.28","1 through 10","2274.35","3568.46","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","AETNA [1001]","HB CH AETNA HMO / PPO","4054.01","58.3","","2190.90","412.50","9264.59","16","3090.92","5417.63","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4033.15","58","","1903.20","1903.20","3826.66","1 through 10","3090.92","5417.63","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4346.06","62.5","","2186.25","2186.25","2186.25","32","3090.92","5417.63","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5076.20","73","","5556.60","5556.60","5556.60","1 through 10","3090.92","5417.63","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","WELLPOINT [1015]","HB CH WELLPOINT","5417.63","77.91","","1955.15","885.83","3150.40","26","3090.92","5417.63","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","4123.54","59.3","","831.03","253.22","2394.88","18","3476.85","5455.18","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5455.18","78.45","","2481.69","1563.74","8149.28","1 through 10","3476.85","5455.18","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","AETNA [1001]","HB CH AETNA HMO / PPO","2415.95","58.3","","2190.90","412.50","9264.59","16","1842.01","3228.59","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2403.52","58","","1903.20","1903.20","3826.66","1 through 10","1842.01","3228.59","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2590.00","62.5","","2186.25","2186.25","2186.25","32","1842.01","3228.59","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3025.12","73","","5556.60","5556.60","5556.60","1 through 10","1842.01","3228.59","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","WELLPOINT [1015]","HB CH WELLPOINT","3228.59","77.91","","1955.15","885.83","3150.40","26","1842.01","3228.59","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2457.39","59.3","","831.03","253.22","2394.88","18","2072","3250.97","percent of total billed charges",""
"GRAFT BONE 10CC KORE FIBER","SUP-ITM-10312074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3250.97","78.45","","2481.69","1563.74","8149.28","1 through 10","2072","3250.97","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","AETNA [1001]","HB CH AETNA HMO / PPO","3614.60","58.3","","2190.90","412.50","9264.59","16","2755.9","4830.42","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3596.00","58","","1903.20","1903.20","3826.66","1 through 10","2755.9","4830.42","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3875.00","62.5","","2186.25","2186.25","2186.25","32","2755.9","4830.42","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4526.00","73","","5556.60","5556.60","5556.60","1 through 10","2755.9","4830.42","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB CH WELLPOINT","4830.42","77.91","","1955.15","885.83","3150.40","26","2755.9","4830.42","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3676.60","59.3","","831.03","253.22","2394.88","18","3100","4863.9","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL MATRIX CELLULAR LG","SUP-ITM-10188189","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4863.90","78.45","","2481.69","1563.74","8149.28","1 through 10","3100","4863.9","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","AETNA [1001]","HB CH AETNA HMO / PPO","1651.30","58.3","","2190.90","412.50","9264.59","16","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1642.80","58","","1903.20","1903.20","3826.66","1 through 10","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1770.26","62.5","","2186.25","2186.25","2186.25","32","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2067.67","73","","5556.60","5556.60","5556.60","1 through 10","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","WELLPOINT [1015]","HB CH WELLPOINT","2206.74","77.91","","1955.15","885.83","3150.40","26","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","1679.63","59.3","","831.03","253.22","2394.88","18","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2222.03","78.45","","2481.69","1563.74","8149.28","1 through 10","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","AETNA [1001]","HB CH AETNA HMO / PPO","1651.30","58.3","","2190.90","412.50","9264.59","16","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1642.80","58","","1903.20","1903.20","3826.66","1 through 10","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1770.26","62.5","","2186.25","2186.25","2186.25","32","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2067.67","73","","5556.60","5556.60","5556.60","1 through 10","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","WELLPOINT [1015]","HB CH WELLPOINT","2206.74","77.91","","1955.15","885.83","3150.40","26","1259.01","2206.74","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","1679.63","59.3","","831.03","253.22","2394.88","18","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2222.03","78.45","","2481.69","1563.74","8149.28","1 through 10","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","AETNA [1001]","HB CH AETNA HMO / PPO","605.15","58.3","","464.71","67.87","1012.10","221","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","605.15","58.3","","293.04","293.04","293.04","11","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","550.14","53","","983.89","983.89","983.89","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","602.04","58","","677.18","677.18","677.18","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","648.75","62.5","","46.58","46.58","46.58","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","757.74","73","","747.15","747.15","747.15","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.39","44.45","","1141.67","481.21","1141.67","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.39","44.45","","76.54","76.54","76.54","1 through 10","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","WELLPOINT [1015]","HB CH WELLPOINT","808.71","77.91","","273.64","94.28","1367.51","138","461.39","808.71","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","615.53","59.3","","720.78","230.14","2010.94","427","519","814.31","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","615.53","59.3","","344.45","344.45","344.45","1 through 10","519","814.31","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","814.31","78.45","","1120.13","1120.13","1120.13","1 through 10","519","814.31","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","814.31","78.45","","456.17","105.33","1284.66","242","519","814.31","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","432.12","324.09","AETNA [1001]","HB CH AETNA HMO / PPO","251.93","58.3","","2190.90","412.50","9264.59","16","192.08","336.66","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","432.12","324.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","250.63","58","","1903.20","1903.20","3826.66","1 through 10","192.08","336.66","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","432.12","324.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","270.08","62.5","","2186.25","2186.25","2186.25","32","192.08","336.66","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","432.12","324.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","315.45","73","","5556.60","5556.60","5556.60","1 through 10","192.08","336.66","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","432.12","324.09","WELLPOINT [1015]","HB CH WELLPOINT","336.66","77.91","","1955.15","885.83","3150.40","26","192.08","336.66","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","432.12","324.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","256.25","59.3","","831.03","253.22","2394.88","18","216.06","339","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","432.12","324.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","339.00","78.45","","2481.69","1563.74","8149.28","1 through 10","216.06","339","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1035.00","776.25","AETNA [1001]","HB CH AETNA HMO / PPO","603.41","58.3","","2190.90","412.50","9264.59","16","460.06","806.37","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","600.30","58","","1903.20","1903.20","3826.66","1 through 10","460.06","806.37","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","646.88","62.5","","2186.25","2186.25","2186.25","32","460.06","806.37","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1035.00","776.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","755.55","73","","5556.60","5556.60","5556.60","1 through 10","460.06","806.37","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1035.00","776.25","WELLPOINT [1015]","HB CH WELLPOINT","806.37","77.91","","1955.15","885.83","3150.40","26","460.06","806.37","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","613.76","59.3","","831.03","253.22","2394.88","18","517.5","811.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","811.96","78.45","","2481.69","1563.74","8149.28","1 through 10","517.5","811.96","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","AETNA [1001]","HB CH AETNA HMO / PPO","986.44","58.3","","464.71","67.87","1012.10","221","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","986.44","58.3","","293.04","293.04","293.04","11","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","896.76","53","","983.89","983.89","983.89","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","981.36","58","","677.18","677.18","677.18","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1057.50","62.5","","46.58","46.58","46.58","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1235.16","73","","747.15","747.15","747.15","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.09","44.45","","1141.67","481.21","1141.67","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.09","44.45","","76.54","76.54","76.54","1 through 10","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.00","1269.00","WELLPOINT [1015]","HB CH WELLPOINT","1318.24","77.91","","273.64","94.28","1367.51","138","752.09","1318.24","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.00","1269.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1003.36","59.3","","720.78","230.14","2010.94","427","846","1327.37","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.00","1269.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1003.36","59.3","","344.45","344.45","344.45","1 through 10","846","1327.37","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.00","1269.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1327.37","78.45","","1120.13","1120.13","1120.13","1 through 10","846","1327.37","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.00","1269.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1327.37","78.45","","456.17","105.33","1284.66","242","846","1327.37","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1908.00","1431.00","AETNA [1001]","HB CH AETNA HMO / PPO","1112.36","58.3","","2190.90","412.50","9264.59","16","848.11","1486.52","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1908.00","1431.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1106.64","58","","1903.20","1903.20","3826.66","1 through 10","848.11","1486.52","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1908.00","1431.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1192.50","62.5","","2186.25","2186.25","2186.25","32","848.11","1486.52","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1908.00","1431.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1392.84","73","","5556.60","5556.60","5556.60","1 through 10","848.11","1486.52","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1908.00","1431.00","WELLPOINT [1015]","HB CH WELLPOINT","1486.52","77.91","","1955.15","885.83","3150.40","26","848.11","1486.52","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1908.00","1431.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1131.44","59.3","","831.03","253.22","2394.88","18","954","1496.83","percent of total billed charges",""
"GRAFT BONE 2.5CC KORE FIBER","SUP-ITM-10312072","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1908.00","1431.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1496.83","78.45","","2481.69","1563.74","8149.28","1 through 10","954","1496.83","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","AETNA [1001]","HB CH AETNA HMO / PPO","1484.76","58.3","","2190.90","412.50","9264.59","16","1132.03","1984.18","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1477.12","58","","1903.20","1903.20","3826.66","1 through 10","1132.03","1984.18","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1591.73","62.5","","2186.25","2186.25","2186.25","32","1132.03","1984.18","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1859.13","73","","5556.60","5556.60","5556.60","1 through 10","1132.03","1984.18","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","WELLPOINT [1015]","HB CH WELLPOINT","1984.18","77.91","","1955.15","885.83","3150.40","26","1132.03","1984.18","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2546.76","1910.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1510.23","59.3","","831.03","253.22","2394.88","18","1273.38","1997.93","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2546.76","1910.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1997.93","78.45","","2481.69","1563.74","8149.28","1 through 10","1273.38","1997.93","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","AETNA [1001]","HB CH AETNA HMO / PPO","708.80","58.3","","2190.90","412.50","9264.59","16","540.41","947.21","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","705.15","58","","1903.20","1903.20","3826.66","1 through 10","540.41","947.21","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","759.86","62.5","","2186.25","2186.25","2186.25","32","540.41","947.21","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","887.52","73","","5556.60","5556.60","5556.60","1 through 10","540.41","947.21","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","WELLPOINT [1015]","HB CH WELLPOINT","947.21","77.91","","1955.15","885.83","3150.40","26","540.41","947.21","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1215.78","911.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.96","59.3","","831.03","253.22","2394.88","18","607.89","953.78","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1215.78","911.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.78","78.45","","2481.69","1563.74","8149.28","1 through 10","607.89","953.78","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","AETNA [1001]","HB CH AETNA HMO / PPO","697.05","58.3","","464.71","67.87","1012.10","221","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","697.05","58.3","","293.04","293.04","293.04","11","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","633.68","53","","983.89","983.89","983.89","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","693.46","58","","677.18","677.18","677.18","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","747.26","62.5","","46.58","46.58","46.58","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","872.80","73","","747.15","747.15","747.15","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.45","44.45","","1141.67","481.21","1141.67","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.45","44.45","","76.54","76.54","76.54","1 through 10","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1195.62","896.71","WELLPOINT [1015]","HB CH WELLPOINT","931.51","77.91","","273.64","94.28","1367.51","138","531.45","931.51","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1195.62","896.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","709.00","59.3","","720.78","230.14","2010.94","427","597.81","937.96","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1195.62","896.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","709.00","59.3","","344.45","344.45","344.45","1 through 10","597.81","937.96","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1195.62","896.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","937.96","78.45","","1120.13","1120.13","1120.13","1 through 10","597.81","937.96","percent of total billed charges",""
"GRAFT BONE 20X30CM FREEZE DRIED READI CANCELLOUS IMPLANTABLE","SUP-ITM-10027275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1195.62","896.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","937.96","78.45","","456.17","105.33","1284.66","242","597.81","937.96","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1403.01","1052.26","AETNA [1001]","HB CH AETNA HMO / PPO","817.95","58.3","","2190.90","412.50","9264.59","16","623.64","1093.09","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1403.01","1052.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","813.75","58","","1903.20","1903.20","3826.66","1 through 10","623.64","1093.09","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1403.01","1052.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","876.88","62.5","","2186.25","2186.25","2186.25","32","623.64","1093.09","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1403.01","1052.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1024.20","73","","5556.60","5556.60","5556.60","1 through 10","623.64","1093.09","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1403.01","1052.26","WELLPOINT [1015]","HB CH WELLPOINT","1093.09","77.91","","1955.15","885.83","3150.40","26","623.64","1093.09","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1403.01","1052.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","831.98","59.3","","831.03","253.22","2394.88","18","701.51","1100.66","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1403.01","1052.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1100.66","78.45","","2481.69","1563.74","8149.28","1 through 10","701.51","1100.66","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","both","","","4206.68","3155.01","AETNA [1001]","HB CH AETNA HMO / PPO","2452.49","58.3","","416.75","416.75","416.75","1 through 10","1869.87","3277.42","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4206.68","3155.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","2494.56","59.3","","7893.60","423.68","7893.60","1 through 10","2103.34","3300.14","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4206.68","3155.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3300.14","78.45","","555.84","329.40","555.84","1 through 10","2103.34","3300.14","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","AETNA [1001]","HB CH AETNA HMO / PPO","1694.78","58.3","","2190.90","412.50","9264.59","16","1292.16","2264.84","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1686.06","58","","1903.20","1903.20","3826.66","1 through 10","1292.16","2264.84","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1816.88","62.5","","2186.25","2186.25","2186.25","32","1292.16","2264.84","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2122.11","73","","5556.60","5556.60","5556.60","1 through 10","1292.16","2264.84","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","WELLPOINT [1015]","HB CH WELLPOINT","2264.84","77.91","","1955.15","885.83","3150.40","26","1292.16","2264.84","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1723.85","59.3","","831.03","253.22","2394.88","18","1453.5","2280.54","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2280.54","78.45","","2481.69","1563.74","8149.28","1 through 10","1453.5","2280.54","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","AETNA [1001]","HB CH AETNA HMO / PPO","2159.26","58.3","","2190.90","412.50","9264.59","16","1646.29","2885.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2148.15","58","","1903.20","1903.20","3826.66","1 through 10","1646.29","2885.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2314.81","62.5","","2186.25","2186.25","2186.25","32","1646.29","2885.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2703.70","73","","5556.60","5556.60","5556.60","1 through 10","1646.29","2885.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","WELLPOINT [1015]","HB CH WELLPOINT","2885.55","77.91","","1955.15","885.83","3150.40","26","1646.29","2885.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2196.29","59.3","","831.03","253.22","2394.88","18","1851.85","2905.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2905.55","78.45","","2481.69","1563.74","8149.28","1 through 10","1851.85","2905.55","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","both","","","3576.00","2682.00","AETNA [1001]","HB CH AETNA HMO / PPO","2084.81","58.3","","2190.90","412.50","9264.59","16","1589.53","2786.06","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2074.08","58","","1903.20","1903.20","3826.66","1 through 10","1589.53","2786.06","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2235.00","62.5","","2186.25","2186.25","2186.25","32","1589.53","2786.06","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","both","","","3576.00","2682.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2610.48","73","","5556.60","5556.60","5556.60","1 through 10","1589.53","2786.06","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","both","","","3576.00","2682.00","WELLPOINT [1015]","HB CH WELLPOINT","2786.06","77.91","","1955.15","885.83","3150.40","26","1589.53","2786.06","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3576.00","2682.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2120.57","59.3","","831.03","253.22","2394.88","18","1788","2805.37","percent of total billed charges",""
"GRAFT BONE 5CC KORE FIBER","SUP-ITM-10312073","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3576.00","2682.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2805.37","78.45","","2481.69","1563.74","8149.28","1 through 10","1788","2805.37","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","464.71","67.87","1012.10","221","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1967.63","58.3","","293.04","293.04","293.04","11","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","983.89","983.89","983.89","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1957.50","58","","677.18","677.18","677.18","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2109.38","62.5","","46.58","46.58","46.58","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","747.15","747.15","747.15","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","1141.67","481.21","1141.67","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","76.54","76.54","76.54","1 through 10","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","273.64","94.28","1367.51","138","1500.19","2629.46","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","720.78","230.14","2010.94","427","1687.5","2647.69","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2001.38","59.3","","344.45","344.45","344.45","1 through 10","1687.5","2647.69","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","1120.13","1120.13","1120.13","1 through 10","1687.5","2647.69","percent of total billed charges",""
"GRAFT BONE 5ML CERAMENT VOID FILLER CERAMIC SYNTHETIC RESORBABLE PASTE SYRINGE","SUP-ITM-10188924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","456.17","105.33","1284.66","242","1687.5","2647.69","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","1779.96","1334.97","AETNA [1001]","HB CH AETNA HMO / PPO","1037.72","58.3","","2190.90","412.50","9264.59","16","791.19","1386.77","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","1779.96","1334.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1032.38","58","","1903.20","1903.20","3826.66","1 through 10","791.19","1386.77","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","1779.96","1334.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1112.48","62.5","","2186.25","2186.25","2186.25","32","791.19","1386.77","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","1779.96","1334.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1299.37","73","","5556.60","5556.60","5556.60","1 through 10","791.19","1386.77","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","1779.96","1334.97","WELLPOINT [1015]","HB CH WELLPOINT","1386.77","77.91","","1955.15","885.83","3150.40","26","791.19","1386.77","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1779.96","1334.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1055.52","59.3","","831.03","253.22","2394.88","18","889.98","1396.38","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1779.96","1334.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1396.38","78.45","","2481.69","1563.74","8149.28","1 through 10","889.98","1396.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","AETNA [1001]","HB CH AETNA HMO / PPO","2587.06","58.3","","2190.90","412.50","9264.59","16","1972.47","3457.26","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2573.75","58","","1903.20","1903.20","3826.66","1 through 10","1972.47","3457.26","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2773.44","62.5","","2186.25","2186.25","2186.25","32","1972.47","3457.26","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","5556.60","5556.60","5556.60","1 through 10","1972.47","3457.26","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","WELLPOINT [1015]","HB CH WELLPOINT","3457.26","77.91","","1955.15","885.83","3150.40","26","1972.47","3457.26","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2631.44","59.3","","831.03","253.22","2394.88","18","2218.75","3481.22","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3481.22","78.45","","2481.69","1563.74","8149.28","1 through 10","2218.75","3481.22","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","AETNA [1001]","HB CH AETNA HMO / PPO","6723.74","58.3","","2190.90","412.50","9264.59","16","5126.42","8985.36","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6689.14","58","","1903.20","1903.20","3826.66","1 through 10","5126.42","8985.36","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7208.13","62.5","","2186.25","2186.25","2186.25","32","5126.42","8985.36","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8419.09","73","","5556.60","5556.60","5556.60","1 through 10","5126.42","8985.36","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","WELLPOINT [1015]","HB CH WELLPOINT","8985.36","77.91","","1955.15","885.83","3150.40","26","5126.42","8985.36","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11533.00","8649.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","6839.07","59.3","","831.03","253.22","2394.88","18","5766.5","9047.64","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL LEFT","SUP-ITM-10079411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11533.00","8649.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9047.64","78.45","","2481.69","1563.74","8149.28","1 through 10","5766.5","9047.64","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","AETNA [1001]","HB CH AETNA HMO / PPO","13992.00","58.3","","2190.90","412.50","9264.59","16","10668","18698.4","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13920.00","58","","1903.20","1903.20","3826.66","1 through 10","10668","18698.4","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","15000.00","62.5","","2186.25","2186.25","2186.25","32","10668","18698.4","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17520.00","73","","5556.60","5556.60","5556.60","1 through 10","10668","18698.4","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","WELLPOINT [1015]","HB CH WELLPOINT","18698.40","77.91","","1955.15","885.83","3150.40","26","10668","18698.4","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14232.00","59.3","","831.03","253.22","2394.88","18","12000","18828","percent of total billed charges",""
"GRAFT BONE KNEE ALLO LATERAL FEMORAL HEMICONDYLE FRESH LEFT","SUP-ITM-10078309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18828.00","78.45","","2481.69","1563.74","8149.28","1 through 10","12000","18828","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","both","","","42100.00","31575.00","AETNA [1001]","HB CH AETNA HMO / PPO","24544.30","58.3","","2190.90","412.50","9264.59","16","18713.45","32800.11","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","both","","","42100.00","31575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","24418.00","58","","1903.20","1903.20","3826.66","1 through 10","18713.45","32800.11","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","both","","","42100.00","31575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","26312.50","62.5","","2186.25","2186.25","2186.25","32","18713.45","32800.11","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","both","","","42100.00","31575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","30733.00","73","","5556.60","5556.60","5556.60","1 through 10","18713.45","32800.11","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","both","","","42100.00","31575.00","WELLPOINT [1015]","HB CH WELLPOINT","32800.11","77.91","","1955.15","885.83","3150.40","26","18713.45","32800.11","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","42100.00","31575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","24965.30","59.3","","831.03","253.22","2394.88","18","21050","33027.45","percent of total billed charges",""
"GRAFT BONE MOPS DISTAL FEMUR RT OC AMBI","SUP-ITM-10269008","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","42100.00","31575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33027.45","78.45","","2481.69","1563.74","8149.28","1 through 10","21050","33027.45","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","AETNA [1001]","HB CH AETNA HMO / PPO","5830.00","58.3","","2190.90","412.50","9264.59","16","4445","7791","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5800.00","58","","1903.20","1903.20","3826.66","1 through 10","4445","7791","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6250.00","62.5","","2186.25","2186.25","2186.25","32","4445","7791","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","5556.60","5556.60","5556.60","1 through 10","4445","7791","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB CH WELLPOINT","7791.00","77.91","","1955.15","885.83","3150.40","26","4445","7791","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","831.03","253.22","2394.88","18","5000","7845","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7845.00","78.45","","2481.69","1563.74","8149.28","1 through 10","5000","7845","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","AETNA [1001]","HB CH AETNA HMO / PPO","13454.94","58.3","","2190.90","412.50","9264.59","16","10258.53","17980.69","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13385.70","58","","1903.20","1903.20","3826.66","1 through 10","10258.53","17980.69","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14424.25","62.5","","2186.25","2186.25","2186.25","32","10258.53","17980.69","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16847.52","73","","5556.60","5556.60","5556.60","1 through 10","10258.53","17980.69","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","WELLPOINT [1015]","HB CH WELLPOINT","17980.69","77.91","","1955.15","885.83","3150.40","26","10258.53","17980.69","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23078.80","17309.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","13685.73","59.3","","831.03","253.22","2394.88","18","11539.4","18105.32","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23078.80","17309.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18105.32","78.45","","2481.69","1563.74","8149.28","1 through 10","11539.4","18105.32","percent of total billed charges",""
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","both","","","4316.00","3237.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","10312.89","10312.89","10312.89","1 through 10","610.45","6884","other","Multiple Surgery"
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4316.00","3237.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2559.39","59.3","","3769.15","3769.15","3769.15","1 through 10","2158","10140.81","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24704.00","18528.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19380.29","78.45","","7551.15","7551.15","7551.15","1 through 10","12352","19380.29","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24704.00","18528.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19380.29","78.45","","7551.15","7551.15","7551.15","1 through 10","12352","19380.29","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X28 121MM BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101382","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8442.00","6331.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6622.75","78.45","","7551.15","7551.15","7551.15","1 through 10","4221","6622.75","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10598.00","7948.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8314.13","78.45","","7551.15","7551.15","7551.15","1 through 10","5299","8314.13","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 124MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101340","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24337.00","18252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19092.38","78.45","","7551.15","7551.15","7551.15","1 through 10","12168.5","19092.38","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24337.00","18252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19092.38","78.45","","7551.15","7551.15","7551.15","1 through 10","12168.5","19092.38","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24337.00","18252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19092.38","78.45","","7551.15","7551.15","7551.15","1 through 10","12168.5","19092.38","percent of total billed charges",""
"GRAFT ENDOVASCULAR 30MM DIA 109X2 ENDOPROSTHESIS FENESTRATED AAA PROXIMALIMAL BODY INTERNAL STENT","SUP-ITM-10101345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24337.00","18252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19092.38","78.45","","7551.15","7551.15","7551.15","1 through 10","12168.5","19092.38","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8442.00","6331.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6622.75","78.45","","7551.15","7551.15","7551.15","1 through 10","4221","6622.75","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6158.00","4618.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4830.95","78.45","","7551.15","7551.15","7551.15","1 through 10","3079","4830.95","percent of total billed charges",""
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","4610.00","3457.50","MEDICARE [2001]","HB NWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","946.1","3591.65","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","4610.00","3457.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1950.54","1950.54","1950.54","1 through 10","946.1","3591.65","other","OPPS APC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","4610.00","3457.50","WELLPOINT [1015]","HB CH WELLPOINT","3591.65","77.91","","5065.84","5065.84","5065.84","1 through 10","849.39","3591.65","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","both","","","1335.59","1001.69","AETNA [1001]","HB CH AETNA HMO / PPO","778.65","58.3","","1786.05","1786.05","1786.05","1 through 10","707.86","1040.56","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","1335.59","1001.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","792.00","59.3","","1845.90","1845.90","1845.90","1 through 10","593.67","1047.77","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","1335.59","1001.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.77","78.45","","2421.72","2421.72","2421.72","1 through 10","593.67","1047.77","percent of total billed charges",""
"GRAFT MESH 1.7IN VENTRALEX EPTFE PATCH UMBILICAL HERNIA REPR SELF EXPAND STRAP CIRCLE SM CS/2EA","SUP-ITM-10188631","CDM","C1781","HCPCS","0278","RC","","","","both","","","1605.00","1203.75","AETNA [1001]","HB CH AETNA HMO / PPO","935.72","58.3","","1862.60","353.13","2619.54","16","713.42","1250.46","percent of total billed charges",""
"GRAFT MESH 1.7IN VENTRALEX EPTFE PATCH UMBILICAL HERNIA REPR SELF EXPAND STRAP CIRCLE SM CS/2EA","SUP-ITM-10188631","CDM","C1781","HCPCS","0278","RC","","","","both","","","1605.00","1203.75","WELLPOINT [1015]","HB CH WELLPOINT","1250.46","77.91","","2876.71","1548.58","2876.71","1 through 10","713.42","1250.46","percent of total billed charges",""
"GRAFT MESH 1.7IN VENTRALEX EPTFE PATCH UMBILICAL HERNIA REPR SELF EXPAND STRAP CIRCLE SM CS/2EA","SUP-ITM-10188631","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1605.00","1203.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","951.77","59.3","","1151.69","270.51","3652.50","14","802.5","1259.12","percent of total billed charges",""
"GRAFT MESH 1.7IN VENTRALEX EPTFE PATCH UMBILICAL HERNIA REPR SELF EXPAND STRAP CIRCLE SM CS/2EA","SUP-ITM-10188631","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1605.00","1203.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1259.12","78.45","","2808.04","1107.07","2808.04","12","802.5","1259.12","percent of total billed charges",""
"GRAFT MESH 10CMX7 BIOLOGICAL PORCINE MATRIX ABDOMINAL SURGISIS HIATAL HERNIA STD","SUP-ITM-10087161","CDM","C1763","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","AETNA [1001]","HB CH AETNA HMO / PPO","2031.76","58.3","","416.75","416.75","416.75","1 through 10","1549.08","2715.16","percent of total billed charges",""
"GRAFT MESH 10CMX7 BIOLOGICAL PORCINE MATRIX ABDOMINAL SURGISIS HIATAL HERNIA STD","SUP-ITM-10087161","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.61","59.3","","7893.60","423.68","7893.60","1 through 10","1742.5","2733.98","percent of total billed charges",""
"GRAFT MESH 10CMX7 BIOLOGICAL PORCINE MATRIX ABDOMINAL SURGISIS HIATAL HERNIA STD","SUP-ITM-10087161","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.98","78.45","","555.84","329.40","555.84","1 through 10","1742.5","2733.98","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN 2.5CM 3.4CM SMALL SURGICAL HERNIA PLUG PERFIX POLYPROPYLENE NON ABSORBENT CS/2EA","SUP-ITM-10188641","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","AETNA [1001]","HB CH AETNA HMO / PPO","376.04","58.3","","1862.60","353.13","2619.54","16","286.7","502.52","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN 2.5CM 3.4CM SMALL SURGICAL HERNIA PLUG PERFIX POLYPROPYLENE NON ABSORBENT CS/2EA","SUP-ITM-10188641","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","WELLPOINT [1015]","HB CH WELLPOINT","502.52","77.91","","2876.71","1548.58","2876.71","1 through 10","286.7","502.52","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN 2.5CM 3.4CM SMALL SURGICAL HERNIA PLUG PERFIX POLYPROPYLENE NON ABSORBENT CS/2EA","SUP-ITM-10188641","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","382.49","59.3","","1151.69","270.51","3652.50","14","322.5","506","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN 2.5CM 3.4CM SMALL SURGICAL HERNIA PLUG PERFIX POLYPROPYLENE NON ABSORBENT CS/2EA","SUP-ITM-10188641","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","506.00","78.45","","2808.04","1107.07","2808.04","12","322.5","506","percent of total billed charges",""
"GRAFT MESH 3.1X4.7IN 8 12CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042158","CDM","C1781","HCPCS","0278","RC","","","","both","","","2055.00","1541.25","AETNA [1001]","HB CH AETNA HMO / PPO","1198.07","58.3","","1862.60","353.13","2619.54","16","913.45","1601.05","percent of total billed charges",""
"GRAFT MESH 3.1X4.7IN 8 12CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042158","CDM","C1781","HCPCS","0278","RC","","","","both","","","2055.00","1541.25","WELLPOINT [1015]","HB CH WELLPOINT","1601.05","77.91","","2876.71","1548.58","2876.71","1 through 10","913.45","1601.05","percent of total billed charges",""
"GRAFT MESH 3.1X4.7IN 8 12CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042158","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2055.00","1541.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1218.62","59.3","","1151.69","270.51","3652.50","14","1027.5","1612.15","percent of total billed charges",""
"GRAFT MESH 3.1X4.7IN 8 12CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042158","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2055.00","1541.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1612.15","78.45","","2808.04","1107.07","2808.04","12","1027.5","1612.15","percent of total billed charges",""
"GRAFT MESH 3IN 7.6CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP CIRCLE - DISCONTINUED PER CONTRACTS","SUP-ITM-10042161","CDM","C1781","HCPCS","0278","RC","","","","both","","","1707.00","1280.25","AETNA [1001]","HB CH AETNA HMO / PPO","995.18","58.3","","1862.60","353.13","2619.54","16","758.76","1329.92","percent of total billed charges",""
"GRAFT MESH 3IN 7.6CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP CIRCLE - DISCONTINUED PER CONTRACTS","SUP-ITM-10042161","CDM","C1781","HCPCS","0278","RC","","","","both","","","1707.00","1280.25","WELLPOINT [1015]","HB CH WELLPOINT","1329.92","77.91","","2876.71","1548.58","2876.71","1 through 10","758.76","1329.92","percent of total billed charges",""
"GRAFT MESH 3IN 7.6CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP CIRCLE - DISCONTINUED PER CONTRACTS","SUP-ITM-10042161","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1707.00","1280.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1012.25","59.3","","1151.69","270.51","3652.50","14","853.5","1339.14","percent of total billed charges",""
"GRAFT MESH 3IN 7.6CM SMALL VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP CIRCLE - DISCONTINUED PER CONTRACTS","SUP-ITM-10042161","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1707.00","1280.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1339.14","78.45","","2808.04","1107.07","2808.04","12","853.5","1339.14","percent of total billed charges",""
"GRAFT MESH 4.3X5.5IN 11 14CM MEDIUM VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042159","CDM","C1781","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","AETNA [1001]","HB CH AETNA HMO / PPO","1810.22","58.3","","1862.60","353.13","2619.54","16","1380.17","2419.11","percent of total billed charges",""
"GRAFT MESH 4.3X5.5IN 11 14CM MEDIUM VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042159","CDM","C1781","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","WELLPOINT [1015]","HB CH WELLPOINT","2419.11","77.91","","2876.71","1548.58","2876.71","1 through 10","1380.17","2419.11","percent of total billed charges",""
"GRAFT MESH 4.3X5.5IN 11 14CM MEDIUM VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042159","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3105.00","2328.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1841.27","59.3","","1151.69","270.51","3652.50","14","1552.5","2435.87","percent of total billed charges",""
"GRAFT MESH 4.3X5.5IN 11 14CM MEDIUM VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042159","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3105.00","2328.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2435.87","78.45","","2808.04","1107.07","2808.04","12","1552.5","2435.87","percent of total billed charges",""
"GRAFT MESH 5.4X7IN 13.8 17.8CM LARGE VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042160","CDM","C1781","HCPCS","0278","RC","","","","both","","","3894.00","2920.50","AETNA [1001]","HB CH AETNA HMO / PPO","2270.20","58.3","","1862.60","353.13","2619.54","16","1730.88","3033.82","percent of total billed charges",""
"GRAFT MESH 5.4X7IN 13.8 17.8CM LARGE VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042160","CDM","C1781","HCPCS","0278","RC","","","","both","","","3894.00","2920.50","WELLPOINT [1015]","HB CH WELLPOINT","3033.82","77.91","","2876.71","1548.58","2876.71","1 through 10","1730.88","3033.82","percent of total billed charges",""
"GRAFT MESH 5.4X7IN 13.8 17.8CM LARGE VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042160","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3894.00","2920.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2309.14","59.3","","1151.69","270.51","3652.50","14","1947","3054.84","percent of total billed charges",""
"GRAFT MESH 5.4X7IN 13.8 17.8CM LARGE VENTRIO EPTFE PATCH UMBILICAL HERNIA REPAIR SELF EXPAND STRAP OVAL - DISCONTINUED PER CONTRACTS","SUP-ITM-10042160","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3894.00","2920.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3054.84","78.45","","2808.04","1107.07","2808.04","12","1947","3054.84","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","AETNA [1001]","HB CH AETNA HMO / PPO","4021.53","58.3","","2190.90","412.50","9264.59","16","3066.16","5374.23","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4000.84","58","","1903.20","1903.20","3826.66","1 through 10","3066.16","5374.23","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4311.25","62.5","","2186.25","2186.25","2186.25","32","3066.16","5374.23","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5035.54","73","","5556.60","5556.60","5556.60","1 through 10","3066.16","5374.23","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","WELLPOINT [1015]","HB CH WELLPOINT","5374.23","77.91","","1955.15","885.83","3150.40","26","3066.16","5374.23","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6898.00","5173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4090.51","59.3","","831.03","253.22","2394.88","18","3449","5411.48","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6898.00","5173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5411.48","78.45","","2481.69","1563.74","8149.28","1 through 10","3449","5411.48","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","AETNA [1001]","HB CH AETNA HMO / PPO","8683.20","58.3","","2190.90","412.50","9264.59","16","6620.38","11603.92","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8638.52","58","","1903.20","1903.20","3826.66","1 through 10","6620.38","11603.92","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9308.75","62.5","","2186.25","2186.25","2186.25","32","6620.38","11603.92","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10872.62","73","","5556.60","5556.60","5556.60","1 through 10","6620.38","11603.92","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","WELLPOINT [1015]","HB CH WELLPOINT","11603.92","77.91","","1955.15","885.83","3150.40","26","6620.38","11603.92","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14894.00","11170.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","8832.14","59.3","","831.03","253.22","2394.88","18","7447","11684.34","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14894.00","11170.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11684.34","78.45","","2481.69","1563.74","8149.28","1 through 10","7447","11684.34","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","both","","","10700.00","8025.00","AETNA [1001]","HB CH AETNA HMO / PPO","6238.10","58.3","","2190.90","412.50","9264.59","16","4756.15","8336.37","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","both","","","10700.00","8025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6206.00","58","","1903.20","1903.20","3826.66","1 through 10","4756.15","8336.37","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","both","","","10700.00","8025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6687.50","62.5","","2186.25","2186.25","2186.25","32","4756.15","8336.37","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","both","","","10700.00","8025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7811.00","73","","5556.60","5556.60","5556.60","1 through 10","4756.15","8336.37","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","both","","","10700.00","8025.00","WELLPOINT [1015]","HB CH WELLPOINT","8336.37","77.91","","1955.15","885.83","3150.40","26","4756.15","8336.37","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10700.00","8025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6345.10","59.3","","831.03","253.22","2394.88","18","5350","8394.15","percent of total billed charges",""
"GRAFT NERVE DIA 2 3MM LENGTH 50 AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10700.00","8025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8394.15","78.45","","2481.69","1563.74","8149.28","1 through 10","5350","8394.15","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","AETNA [1001]","HB CH AETNA HMO / PPO","1530.95","58.3","","2190.90","412.50","9264.59","16","1167.25","2045.91","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1523.07","58","","1903.20","1903.20","3826.66","1 through 10","1167.25","2045.91","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1641.24","62.5","","2186.25","2186.25","2186.25","32","1167.25","2045.91","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1916.97","73","","5556.60","5556.60","5556.60","1 through 10","1167.25","2045.91","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","WELLPOINT [1015]","HB CH WELLPOINT","2045.91","77.91","","1955.15","885.83","3150.40","26","1167.25","2045.91","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1557.21","59.3","","831.03","253.22","2394.88","18","1313","2060.09","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2060.09","78.45","","2481.69","1563.74","8149.28","1 through 10","1313","2060.09","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","10802.44","8101.83","AETNA [1001]","HB CH AETNA HMO / PPO","6297.82","58.3","","2190.90","412.50","9264.59","16","4801.68","8416.18","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","10802.44","8101.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6265.42","58","","1903.20","1903.20","3826.66","1 through 10","4801.68","8416.18","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","10802.44","8101.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6751.53","62.5","","2186.25","2186.25","2186.25","32","4801.68","8416.18","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","10802.44","8101.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7885.78","73","","5556.60","5556.60","5556.60","1 through 10","4801.68","8416.18","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","10802.44","8101.83","WELLPOINT [1015]","HB CH WELLPOINT","8416.18","77.91","","1955.15","885.83","3150.40","26","4801.68","8416.18","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10802.44","8101.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","6405.85","59.3","","831.03","253.22","2394.88","18","5401.22","8474.51","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10802.44","8101.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8474.51","78.45","","2481.69","1563.74","8149.28","1 through 10","5401.22","8474.51","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","AETNA [1001]","HB CH AETNA HMO / PPO","1974.18","58.3","","2190.90","412.50","9264.59","16","1505.19","2638.23","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1964.03","58","","1903.20","1903.20","3826.66","1 through 10","1505.19","2638.23","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2116.41","62.5","","2186.25","2186.25","2186.25","32","1505.19","2638.23","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2471.96","73","","5556.60","5556.60","5556.60","1 through 10","1505.19","2638.23","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","WELLPOINT [1015]","HB CH WELLPOINT","2638.23","77.91","","1955.15","885.83","3150.40","26","1505.19","2638.23","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3386.25","2539.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2008.05","59.3","","831.03","253.22","2394.88","18","1693.13","2656.51","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3386.25","2539.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2656.51","78.45","","2481.69","1563.74","8149.28","1 through 10","1693.13","2656.51","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","AETNA [1001]","HB CH AETNA HMO / PPO","1194.57","58.3","","1862.60","353.13","2619.54","16","910.78","1596.38","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","WELLPOINT [1015]","HB CH WELLPOINT","1596.38","77.91","","2876.71","1548.58","2876.71","1 through 10","910.78","1596.38","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2049.00","1536.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1215.06","59.3","","1151.69","270.51","3652.50","14","1024.5","1607.44","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2049.00","1536.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1607.44","78.45","","2808.04","1107.07","2808.04","12","1024.5","1607.44","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4408.00","3306.00","AETNA [1001]","HB CH AETNA HMO / PPO","2569.86","58.3","","52.60","33.42","52.60","1932","96.52","3434.27","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4408.00","3306.00","WELLPOINT [1015]","HB CH WELLPOINT","3434.27","77.91","","77.77","77.77","77.77","240","96.52","3434.27","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4408.00","3306.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2300.98","52.2","","47.77","47.77","47.77","480","2204","2300.98","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4538.00","3403.50","AETNA [1001]","HB CH AETNA HMO / PPO","2645.65","58.3","","52.60","33.42","52.60","1932","96.52","3535.56","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4538.00","3403.50","WELLPOINT [1015]","HB CH WELLPOINT","3535.56","77.91","","77.77","77.77","77.77","240","96.52","3535.56","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4538.00","3403.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2368.84","52.2","","47.77","47.77","47.77","480","2269","2368.84","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","AETNA [1001]","HB CH AETNA HMO / PPO","5635.28","58.3","","52.60","33.42","52.60","1932","96.52","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","WELLPOINT [1015]","HB CH WELLPOINT","7530.78","77.91","","77.77","77.77","77.77","240","96.52","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9666.00","7249.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5045.65","52.2","","47.77","47.77","47.77","480","4833","5045.65","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7554.00","5665.50","AETNA [1001]","HB CH AETNA HMO / PPO","4403.98","58.3","","52.60","33.42","52.60","1932","96.52","5885.32","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7554.00","5665.50","WELLPOINT [1015]","HB CH WELLPOINT","5885.32","77.91","","77.77","77.77","77.77","240","96.52","5885.32","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7554.00","5665.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3943.19","52.2","","47.77","47.77","47.77","480","3777","3943.19","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","AETNA [1001]","HB CH AETNA HMO / PPO","4535.74","58.3","","52.60","33.42","52.60","1932","96.52","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","WELLPOINT [1015]","HB CH WELLPOINT","6061.40","77.91","","77.77","77.77","77.77","240","96.52","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7780.00","5835.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4061.16","52.2","","47.77","47.77","47.77","480","3890","4061.16","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM HUMAN ALLODERM EXTRA LG CONTOURED MED THICKNESS REGENERATIVE MATRIX","SUP-ITM-10190839","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11446.00","8584.50","AETNA [1001]","HB CH AETNA HMO / PPO","6673.02","58.3","","52.60","33.42","52.60","1932","96.52","8917.58","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM HUMAN ALLODERM EXTRA LG CONTOURED MED THICKNESS REGENERATIVE MATRIX","SUP-ITM-10190839","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11446.00","8584.50","WELLPOINT [1015]","HB CH WELLPOINT","8917.58","77.91","","77.77","77.77","77.77","240","96.52","8917.58","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM HUMAN ALLODERM EXTRA LG CONTOURED MED THICKNESS REGENERATIVE MATRIX","SUP-ITM-10190839","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11446.00","8584.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5974.81","52.2","","47.77","47.77","47.77","480","5723","5974.81","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM XL HUMAN ALLODERM CONTOURED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10190852","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11790.00","8842.50","AETNA [1001]","HB CH AETNA HMO / PPO","6873.57","58.3","","52.60","33.42","52.60","1932","96.52","9185.59","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM XL HUMAN ALLODERM CONTOURED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10190852","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11790.00","8842.50","WELLPOINT [1015]","HB CH WELLPOINT","9185.59","77.91","","77.77","77.77","77.77","240","96.52","9185.59","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM XL HUMAN ALLODERM CONTOURED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10190852","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11790.00","8842.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","6154.38","52.2","","47.77","47.77","47.77","480","5895","6154.38","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","AETNA [1001]","HB CH AETNA HMO / PPO","1194.74","58.3","","464.71","67.87","1012.10","221","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1194.74","58.3","","293.04","293.04","293.04","11","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.13","53","","983.89","983.89","983.89","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1188.59","58","","677.18","677.18","677.18","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1280.81","62.5","","46.58","46.58","46.58","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1495.99","73","","747.15","747.15","747.15","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","910.91","44.45","","1141.67","481.21","1141.67","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","910.91","44.45","","76.54","76.54","76.54","1 through 10","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","both","","","2049.30","1536.97","WELLPOINT [1015]","HB CH WELLPOINT","1596.61","77.91","","273.64","94.28","1367.51","138","910.91","1596.61","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2049.30","1536.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1215.23","59.3","","720.78","230.14","2010.94","427","1024.65","1607.68","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2049.30","1536.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1215.23","59.3","","344.45","344.45","344.45","1 through 10","1024.65","1607.68","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2049.30","1536.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1607.68","78.45","","1120.13","1120.13","1120.13","1 through 10","1024.65","1607.68","percent of total billed charges",""
"GRAFT TISSUE 13 TO 15MM FREEZE DRIED CALCANEOUS CROSS SECTION PATH THICK","SUP-ITM-10010773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2049.30","1536.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1607.68","78.45","","456.17","105.33","1284.66","242","1024.65","1607.68","percent of total billed charges",""
"GRAFT TISSUE 16X20CM ALLODERM ALLOGRAFT REGENERATIVE MATRIX AMBIENT TEMP THICK","SUP-ITM-10190854","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18314.00","13735.50","AETNA [1001]","HB CH AETNA HMO / PPO","10677.06","58.3","","52.60","33.42","52.60","1932","96.52","14268.44","percent of total billed charges",""
"GRAFT TISSUE 16X20CM ALLODERM ALLOGRAFT REGENERATIVE MATRIX AMBIENT TEMP THICK","SUP-ITM-10190854","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18314.00","13735.50","WELLPOINT [1015]","HB CH WELLPOINT","14268.44","77.91","","77.77","77.77","77.77","240","96.52","14268.44","percent of total billed charges",""
"GRAFT TISSUE 16X20CM ALLODERM ALLOGRAFT REGENERATIVE MATRIX AMBIENT TEMP THICK","SUP-ITM-10190854","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","18314.00","13735.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","9559.91","52.2","","47.77","47.77","47.77","480","9157","9559.91","percent of total billed charges",""
"GRAFT TISSUE 20.1X23.6 RTU ALLODERM RESTORE LARGE MEDTHICK PERFORATED","SUP-ITM-10311449","CDM","Q4116","HCPCS","0636","RC","","","","both","","","22264.00","16698.00","AETNA [1001]","HB CH AETNA HMO / PPO","12979.91","58.3","","52.60","33.42","52.60","1932","96.52","17345.88","percent of total billed charges",""
"GRAFT TISSUE 20.1X23.6 RTU ALLODERM RESTORE LARGE MEDTHICK PERFORATED","SUP-ITM-10311449","CDM","Q4116","HCPCS","0636","RC","","","","both","","","22264.00","16698.00","WELLPOINT [1015]","HB CH WELLPOINT","17345.88","77.91","","77.77","77.77","77.77","240","96.52","17345.88","percent of total billed charges",""
"GRAFT TISSUE 20.1X23.6 RTU ALLODERM RESTORE LARGE MEDTHICK PERFORATED","SUP-ITM-10311449","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","22264.00","16698.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","11621.81","52.2","","47.77","47.77","47.77","480","11132","11621.81","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18864.00","14148.00","AETNA [1001]","HB CH AETNA HMO / PPO","10997.71","58.3","","52.60","33.42","52.60","1932","96.52","14696.94","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18864.00","14148.00","WELLPOINT [1015]","HB CH WELLPOINT","14696.94","77.91","","77.77","77.77","77.77","240","96.52","14696.94","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","18864.00","14148.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","9847.01","52.2","","47.77","47.77","47.77","480","9432","9847.01","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PERFORATED","SUP-ITM-10174653","CDM","C1781","HCPCS","0278","RC","","","","both","","","38780.00","29085.00","AETNA [1001]","HB CH AETNA HMO / PPO","22608.74","58.3","","1862.60","353.13","2619.54","16","17237.71","30213.5","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PERFORATED","SUP-ITM-10174653","CDM","C1781","HCPCS","0278","RC","","","","both","","","38780.00","29085.00","WELLPOINT [1015]","HB CH WELLPOINT","30213.50","77.91","","2876.71","1548.58","2876.71","1 through 10","17237.71","30213.5","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PERFORATED","SUP-ITM-10174653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","38780.00","29085.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","22996.54","59.3","","1151.69","270.51","3652.50","14","19390","30422.91","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PERFORATED","SUP-ITM-10174653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","38780.00","29085.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","30422.91","78.45","","2808.04","1107.07","2808.04","12","19390","30422.91","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PORCINE PERFORATED RECONSTRUCTIVE MATRIX FIRM","SUP-ITM-10174655","CDM","C1781","HCPCS","0278","RC","","","","both","","","29088.00","21816.00","AETNA [1001]","HB CH AETNA HMO / PPO","16958.30","58.3","","1862.60","353.13","2619.54","16","12929.62","22662.46","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PORCINE PERFORATED RECONSTRUCTIVE MATRIX FIRM","SUP-ITM-10174655","CDM","C1781","HCPCS","0278","RC","","","","both","","","29088.00","21816.00","WELLPOINT [1015]","HB CH WELLPOINT","22662.46","77.91","","2876.71","1548.58","2876.71","1 through 10","12929.62","22662.46","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PORCINE PERFORATED RECONSTRUCTIVE MATRIX FIRM","SUP-ITM-10174655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","29088.00","21816.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","17249.18","59.3","","1151.69","270.51","3652.50","14","14544","22819.54","percent of total billed charges",""
"GRAFT TISSUE 20X40CM STRATTICE PORCINE PERFORATED RECONSTRUCTIVE MATRIX FIRM","SUP-ITM-10174655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","29088.00","21816.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","22819.54","78.45","","2808.04","1107.07","2808.04","12","14544","22819.54","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","both","","","1753.38","1315.03","AETNA [1001]","HB CH AETNA HMO / PPO","1022.22","58.3","","416.75","416.75","416.75","1 through 10","779.38","1366.06","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1753.38","1315.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1039.75","59.3","","7893.60","423.68","7893.60","1 through 10","876.69","1375.53","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1753.38","1315.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1375.53","78.45","","555.84","329.40","555.84","1 through 10","876.69","1375.53","percent of total billed charges",""
"GRAFT TISSUE 4X16CM THICK 2.0 TO 2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132964","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4330.00","3247.50","AETNA [1001]","HB CH AETNA HMO / PPO","2524.39","58.3","","52.60","33.42","52.60","1932","96.52","3373.5","percent of total billed charges",""
"GRAFT TISSUE 4X16CM THICK 2.0 TO 2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132964","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4330.00","3247.50","WELLPOINT [1015]","HB CH WELLPOINT","3373.50","77.91","","77.77","77.77","77.77","240","96.52","3373.5","percent of total billed charges",""
"GRAFT TISSUE 4X16CM THICK 2.0 TO 2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132964","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4330.00","3247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2260.26","52.2","","47.77","47.77","47.77","480","2165","2260.26","percent of total billed charges",""
"GRAFT TISSUE 6X16CM THICK 2-2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132968","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","AETNA [1001]","HB CH AETNA HMO / PPO","3203.00","58.3","","52.60","33.42","52.60","1932","96.52","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM THICK 2-2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132968","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","WELLPOINT [1015]","HB CH WELLPOINT","4280.38","77.91","","77.77","77.77","77.77","240","96.52","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM THICK 2-2.79 HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132968","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5494.00","4120.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2867.87","52.2","","47.77","47.77","47.77","480","2747","2867.87","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM ALLOGRAFT REGENERATIVE READY TO USE MATRIX THIN","SUP-ITM-10100898","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","AETNA [1001]","HB CH AETNA HMO / PPO","4271.06","58.3","","52.60","33.42","52.60","1932","96.52","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM ALLOGRAFT REGENERATIVE READY TO USE MATRIX THIN","SUP-ITM-10100898","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","WELLPOINT [1015]","HB CH WELLPOINT","5707.69","77.91","","77.77","77.77","77.77","240","96.52","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM ALLOGRAFT REGENERATIVE READY TO USE MATRIX THIN","SUP-ITM-10100898","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7326.00","5494.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3824.17","52.2","","47.77","47.77","47.77","480","3663","3824.17","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9384.00","7038.00","AETNA [1001]","HB CH AETNA HMO / PPO","5470.87","58.3","","52.60","33.42","52.60","1932","96.52","7311.07","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9384.00","7038.00","WELLPOINT [1015]","HB CH WELLPOINT","7311.07","77.91","","77.77","77.77","77.77","240","96.52","7311.07","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9384.00","7038.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4898.45","52.2","","47.77","47.77","47.77","480","4692","4898.45","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","AETNA [1001]","HB CH AETNA HMO / PPO","2062.07","58.3","","1862.60","353.13","2619.54","16","1572.2","2755.68","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","WELLPOINT [1015]","HB CH WELLPOINT","2755.68","77.91","","2876.71","1548.58","2876.71","1 through 10","1572.2","2755.68","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3537.00","2652.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2097.44","59.3","","1151.69","270.51","3652.50","14","1768.5","2774.78","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3537.00","2652.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2774.78","78.45","","2808.04","1107.07","2808.04","12","1768.5","2774.78","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","both","","","13344.00","10008.00","AETNA [1001]","HB CH AETNA HMO / PPO","7779.55","58.3","","2190.90","412.50","9264.59","16","5931.41","10396.31","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","both","","","13344.00","10008.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7739.52","58","","1903.20","1903.20","3826.66","1 through 10","5931.41","10396.31","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","both","","","13344.00","10008.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8340.00","62.5","","2186.25","2186.25","2186.25","32","5931.41","10396.31","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","both","","","13344.00","10008.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9741.12","73","","5556.60","5556.60","5556.60","1 through 10","5931.41","10396.31","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","both","","","13344.00","10008.00","WELLPOINT [1015]","HB CH WELLPOINT","10396.31","77.91","","1955.15","885.83","3150.40","26","5931.41","10396.31","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13344.00","10008.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7912.99","59.3","","831.03","253.22","2394.88","18","6672","10468.37","percent of total billed charges",""
"GRAFT VASCULAR 3.0MMX31 45CM CARDIO SAPHENOUS VEIN CRYOPRESERVED","SUP-ITM-10017027","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13344.00","10008.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10468.37","78.45","","2481.69","1563.74","8149.28","1 through 10","6672","10468.37","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","AETNA [1001]","HB CH AETNA HMO / PPO","1515.80","58.3","","14157.42","7078.71","14157.42","1 through 10","1115.4","4795.51","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","4066.21","4066.21","4066.21","1 through 10","1115.4","4795.51","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,064). Procedure 2, Per diem ($1,532). Procedures 3 - 9999, Per diem ($766).","3064.00","3064.00","3064.00","1 through 10","1115.4","4795.51","per diem",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","1609.00","3218.00","1 through 10","1115.4","4795.51","per diem",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4268.17","4268.17","4268.17","1 through 10","1115.4","4795.51","other","OPPS APC"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2355.85","2355.85","2355.85","1 through 10","1300","7178","other","ASC "
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2359.12","2310.17","4718.23","1 through 10","1300","7178","other","ASC "
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3250.21","3250.21","3250.21","1 through 10","1300","7178","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3416.17","3416.17","3416.17","1 through 10","1300","7178","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","438.42","58.3","","7078.71","7078.71","7078.71","1 through 10","322.61","585.88","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","5585.11","5585.11","5585.11","1 through 10","322.61","585.88","per diem",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","10079.70","3724.80","10079.70","1 through 10","322.61","585.88","per diem",""
"Grafting of Autologous Soft Tiss by Direct Exc","PX-76002654","CDM","15769","CPT","0761","RC","","","","outpatient","","","2623.00","1967.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3250.21","3250.21","3250.21","1 through 10","1311.5","7178","other","Multiple Surgery"
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","464.71","67.87","1012.10","221","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","293.04","293.04","293.04","11","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","983.89","983.89","983.89","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","677.18","677.18","677.18","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","46.58","46.58","46.58","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","747.15","747.15","747.15","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1141.67","481.21","1141.67","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","76.54","76.54","76.54","1 through 10","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","273.64","94.28","1367.51","138","1600.2","2804.76","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","720.78","230.14","2010.94","427","1800","2824.2","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","344.45","344.45","344.45","1 through 10","1800","2824.2","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1120.13","1120.13","1120.13","1 through 10","1800","2824.2","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","456.17","105.33","1284.66","242","1800","2824.2","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","205.28","74.28","205.28","1 through 10","44.28","170.56","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","MEDICARE [2001]","HB NWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","1 through 10","44.28","170.56","other","OPPS APC"
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","206.36","206.36","206.36","1 through 10","44.28","170.56","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","153.54","153.54","153.54","12","56.93","125.76","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","201.42","100.71","201.42","1 through 10","56.93","125.76","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","AETNA [1001]","HB CH AETNA HMO / PPO","209.30","58.3","","197.88","150.80","328.31","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","HUMANA [1012]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","MEDICARE [2001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","63.45","63.45","109","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","31.09","62.18","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.58","44.45","","318.00","159.00","318.00","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","57.96","62.19","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.58","44.45","","159.00","159.00","159.00","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","WELLPOINT [1015]","HB CH WELLPOINT","279.70","77.91","","612.71","274.87","623.87","36","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","359.00","269.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.89","59.3","","204.51","204.51","409.02","93","90.37","281.64","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.64","78.45","","268.31","159.00","536.62","86","90.37","281.64","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","AETNA [1001]","HB CH AETNA HMO / PPO","205.22","58.3","","387.82","193.91","581.73","103","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","125","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","256.96","73","","249.66","249.66","249.66","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","205.22","58.3","","387.82","387.82","387.82","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","MEDICARE [2001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","63.45","63.45","1191","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","256.96","73","","387.82","193.91","1680.28","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TRICARE [160005]","HB NWH TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","63.45","63.45","342.00","1 through 10","60.28","274.24","other","Tricare OPPS"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","20.73","124.36","184","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.45","63.45","63.45","30","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.46","44.45","","262.93","155.82","779.10","34","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","62.18","62.39","84","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.46","44.45","","311.64","262.93","525.86","11","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","WELLPOINT [1015]","HB CH WELLPOINT","274.24","77.91","","538.72","269.36","1222.72","185","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.74","59.3","","400.82","200.41","1202.46","996","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","208.74","59.3","","189.90","189.90","189.90","1 through 10","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","276.14","78.45","","788.79","262.93","788.79","1 through 10","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.14","78.45","","525.86","262.93","1314.65","1002","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","AETNA [1001]","HB CH AETNA HMO / PPO","473.40","58.3","","1791.72","895.86","2687.58","15","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1281.57","392.31","1281.57","1 through 10","360.93","1456.11","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","592.76","73","","447.93","447.93","447.93","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","360.93","1456.11","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.93","44.45","","719.84","359.92","719.84","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","360.93","1456.11","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.93","44.45","","2429.40","2429.40","2429.40","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","WELLPOINT [1015]","HB CH WELLPOINT","632.63","77.91","","1833.45","622.20","3111.00","30","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","481.52","59.3","","2711.28","462.94","6462.41","118","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","637.01","78.45","","607.35","607.35","607.35","1 through 10","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","637.01","78.45","","1214.70","607.35","3644.10","89","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","669.63","669.63","669.63","1 through 10","540.07","2963.62","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","2111.16","2111.16","2111.16","1 through 10","540.07","2963.62","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","692.07","691.33","733.36","1 through 10","607.5","1886.45","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","907.95","907.95","907.95","1 through 10","607.5","1886.45","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","907.95","538.06","907.95","14","607.5","1886.45","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","125.00","93.75","WELLPOINT [1015]","HB CH WELLPOINT","97.39","77.91","","192.18","192.18","192.18","1 through 10","27.63","97.39","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","125.00","93.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.13","59.3","","275.42","108.30","275.42","1 through 10","30.43","98.06","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.06","78.45","","93.79","93.79","187.58","1 through 10","30.43","98.06","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","16.34","131.1","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","1 through 10","17.2","108.26","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","103.02","103.02","1 through 10","17.2","108.26","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","AETNA [1001]","HB CH AETNA HMO / PPO","2066.01","58.3","","1530.90","1160.93","1884.08","89","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1878.19","53","","5253.92","5253.92","5253.92","1 through 10","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2055.38","58","","12181.47","12181.47","12181.47","1 through 10","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2214.84","62.5","","1350.68","1350.68","1350.68","1 through 10","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1575.20","44.45","","1910.74","891.94","1910.74","1 through 10","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3543.75","2657.81","WELLPOINT [1015]","HB CH WELLPOINT","2760.94","77.91","","1829.79","1561.50","2617.12","88","1575.2","2760.94","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3543.75","2657.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2101.44","59.3","","1359.46","1201.30","1689.00","61","1771.88","2780.07","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3543.75","2657.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2101.44","59.3","","1718.92","1718.92","1718.92","1 through 10","1771.88","2780.07","percent of total billed charges",""
"GUIDE SHOULDER TOTAL COMPREHENSIVE WITH BONE MODEL RT","SUP-ITM-10281436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3543.75","2657.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2780.07","78.45","","1910.74","1019.06","2344.84","74","1771.88","2780.07","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","AETNA [1001]","HB CH AETNA HMO / PPO","1754.25","58.3","","1530.90","1160.93","1884.08","89","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1594.77","53","","5253.92","5253.92","5253.92","1 through 10","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1745.22","58","","12181.47","12181.47","12181.47","1 through 10","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1880.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1337.50","44.45","","1910.74","891.94","1910.74","1 through 10","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","WELLPOINT [1015]","HB CH WELLPOINT","2344.31","77.91","","1829.79","1561.50","2617.12","88","1337.5","2344.31","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3009.00","2256.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1784.34","59.3","","1359.46","1201.30","1689.00","61","1504.5","2360.56","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3009.00","2256.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1784.34","59.3","","1718.92","1718.92","1718.92","1 through 10","1504.5","2360.56","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3009.00","2256.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2360.56","78.45","","1910.74","1019.06","2344.84","74","1504.5","2360.56","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","AETNA [1001]","HB CH AETNA HMO / PPO","245.17","58.3","","52.78","35.48","309.60","1 through 10","186.93","327.64","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.89","53","","173.31","173.31","173.31","1 through 10","186.93","327.64","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.84","62.5","","26.48","26.48","26.48","1 through 10","186.93","327.64","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.93","44.45","","127.34","127.34","127.34","1 through 10","186.93","327.64","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","WELLPOINT [1015]","HB CH WELLPOINT","327.64","77.91","","99.24","60.15","134.68","19","186.93","327.64","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.54","315.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.38","59.3","","59.44","59.44","59.44","1 through 10","210.27","329.91","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.54","315.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.91","78.45","","239.87","239.87","239.87","1 through 10","210.27","329.91","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.54","315.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.91","78.45","","77.27","46.21","95.91","26","210.27","329.91","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","AETNA [1001]","HB CH AETNA HMO / PPO","2331.99","58.3","","52.78","35.48","309.60","1 through 10","1777.99","3116.38","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2119.99","53","","173.31","173.31","173.31","1 through 10","1777.99","3116.38","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2499.99","62.5","","26.48","26.48","26.48","1 through 10","1777.99","3116.38","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.99","44.45","","127.34","127.34","127.34","1 through 10","1777.99","3116.38","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","WELLPOINT [1015]","HB CH WELLPOINT","3116.38","77.91","","99.24","60.15","134.68","19","1777.99","3116.38","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3999.98","2999.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2371.99","59.3","","59.44","59.44","59.44","1 through 10","1999.99","3137.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3999.98","2999.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3137.98","78.45","","239.87","239.87","239.87","1 through 10","1999.99","3137.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3999.98","2999.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3137.98","78.45","","77.27","46.21","95.91","26","1999.99","3137.98","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB CH AETNA HMO / PPO","59.47","58.3","","52.78","35.48","309.60","1 through 10","45.34","79.47","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","both","","","102.00","76.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.06","53","","173.31","173.31","173.31","1 through 10","45.34","79.47","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","63.75","62.5","","26.48","26.48","26.48","1 through 10","45.34","79.47","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.34","44.45","","127.34","127.34","127.34","1 through 10","45.34","79.47","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","both","","","102.00","76.50","WELLPOINT [1015]","HB CH WELLPOINT","79.47","77.91","","99.24","60.15","134.68","19","45.34","79.47","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","59.44","59.44","59.44","1 through 10","51","80.02","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","102.00","76.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","80.02","78.45","","239.87","239.87","239.87","1 through 10","51","80.02","percent of total billed charges",""
"GUIDEWIRE 0.9X150MM SINGLE TROCAR","SUP-ITM-10327456","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.02","78.45","","77.27","46.21","95.91","26","51","80.02","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","52.78","35.48","309.60","1 through 10","80.01","140.24","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","173.31","173.31","173.31","1 through 10","80.01","140.24","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.50","62.5","","26.48","26.48","26.48","1 through 10","80.01","140.24","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","127.34","127.34","127.34","1 through 10","80.01","140.24","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","99.24","60.15","134.68","19","80.01","140.24","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","59.44","59.44","59.44","1 through 10","90","141.21","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","239.87","239.87","239.87","1 through 10","90","141.21","percent of total billed charges",""
"GUIDEWIRE 1.4MM","SUP-ITM-10192003","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","77.27","46.21","95.91","26","90","141.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","AETNA [1001]","HB CH AETNA HMO / PPO","60.90","58.3","","52.78","35.48","309.60","1 through 10","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.36","53","","173.31","173.31","173.31","1 through 10","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.29","62.5","","26.48","26.48","26.48","1 through 10","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.43","44.45","","127.34","127.34","127.34","1 through 10","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","WELLPOINT [1015]","HB CH WELLPOINT","81.38","77.91","","99.24","60.15","134.68","19","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.46","78.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.94","59.3","","59.44","59.44","59.44","1 through 10","52.23","81.95","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.46","78.34","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","81.95","78.45","","239.87","239.87","239.87","1 through 10","52.23","81.95","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.46","78.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.95","78.45","","77.27","46.21","95.91","26","52.23","81.95","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","438.00","328.50","AETNA [1001]","HB CH AETNA HMO / PPO","255.35","58.3","","52.78","35.48","309.60","1 through 10","194.69","341.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","438.00","328.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","232.14","53","","173.31","173.31","173.31","1 through 10","194.69","341.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","438.00","328.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","273.75","62.5","","26.48","26.48","26.48","1 through 10","194.69","341.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","438.00","328.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.69","44.45","","127.34","127.34","127.34","1 through 10","194.69","341.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","438.00","328.50","WELLPOINT [1015]","HB CH WELLPOINT","341.25","77.91","","99.24","60.15","134.68","19","194.69","341.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","438.00","328.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","259.73","59.3","","59.44","59.44","59.44","1 through 10","219","343.61","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","438.00","328.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","343.61","78.45","","239.87","239.87","239.87","1 through 10","219","343.61","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","438.00","328.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","343.61","78.45","","77.27","46.21","95.91","26","219","343.61","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","AETNA [1001]","HB CH AETNA HMO / PPO","307.12","58.3","","52.78","35.48","309.60","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","279.20","53","","173.31","173.31","173.31","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","329.25","62.5","","26.48","26.48","26.48","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.16","44.45","","127.34","127.34","127.34","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","WELLPOINT [1015]","HB CH WELLPOINT","410.43","77.91","","99.24","60.15","134.68","19","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","312.39","59.3","","59.44","59.44","59.44","1 through 10","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","413.27","78.45","","239.87","239.87","239.87","1 through 10","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 10 .035IN STRAIGHT DREAM TIP HIGH PERFORMANCE HYDROPHILIC ENCAPSULATED HYDRA JAGWIRE METAL PTF BX/2EA","SUP-ITM-10022776","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","413.27","78.45","","77.27","46.21","95.91","26","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","AETNA [1001]","HB CH AETNA HMO / PPO","52.47","58.3","","52.78","35.48","309.60","1 through 10","40.01","70.12","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","47.70","53","","173.31","173.31","173.31","1 through 10","40.01","70.12","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","56.25","62.5","","26.48","26.48","26.48","1 through 10","40.01","70.12","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.01","44.45","","127.34","127.34","127.34","1 through 10","40.01","70.12","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","WELLPOINT [1015]","HB CH WELLPOINT","70.12","77.91","","99.24","60.15","134.68","19","40.01","70.12","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.00","67.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","53.37","59.3","","59.44","59.44","59.44","1 through 10","45","70.61","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","239.87","239.87","239.87","1 through 10","45","70.61","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","77.27","46.21","95.91","26","45","70.61","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","52.78","35.48","309.60","1 through 10","26.67","46.75","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","173.31","173.31","173.31","1 through 10","26.67","46.75","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37.50","62.5","","26.48","26.48","26.48","1 through 10","26.67","46.75","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","127.34","127.34","127.34","1 through 10","26.67","46.75","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","99.24","60.15","134.68","19","26.67","46.75","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","59.44","59.44","59.44","1 through 10","30","47.07","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","239.87","239.87","239.87","1 through 10","30","47.07","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","77.27","46.21","95.91","26","30","47.07","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","AETNA [1001]","HB CH AETNA HMO / PPO","53.17","58.3","","52.78","35.48","309.60","1 through 10","40.54","71.05","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","48.34","53","","173.31","173.31","173.31","1 through 10","40.54","71.05","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","57.00","62.5","","26.48","26.48","26.48","1 through 10","40.54","71.05","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.54","44.45","","127.34","127.34","127.34","1 through 10","40.54","71.05","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","WELLPOINT [1015]","HB CH WELLPOINT","71.05","77.91","","99.24","60.15","134.68","19","40.54","71.05","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.20","68.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.08","59.3","","59.44","59.44","59.44","1 through 10","45.6","71.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.20","68.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","71.55","78.45","","239.87","239.87","239.87","1 through 10","45.6","71.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.20","68.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","71.55","78.45","","77.27","46.21","95.91","26","45.6","71.55","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","AETNA [1001]","HB CH AETNA HMO / PPO","62.77","58.3","","52.78","35.48","309.60","1 through 10","47.86","83.89","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.07","53","","173.31","173.31","173.31","1 through 10","47.86","83.89","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","67.29","62.5","","26.48","26.48","26.48","1 through 10","47.86","83.89","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.86","44.45","","127.34","127.34","127.34","1 through 10","47.86","83.89","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","WELLPOINT [1015]","HB CH WELLPOINT","83.89","77.91","","99.24","60.15","134.68","19","47.86","83.89","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","107.67","80.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.85","59.3","","59.44","59.44","59.44","1 through 10","53.84","84.47","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","239.87","239.87","239.87","1 through 10","53.84","84.47","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","77.27","46.21","95.91","26","53.84","84.47","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","AETNA [1001]","HB CH AETNA HMO / PPO","27.98","58.3","","52.78","35.48","309.60","1 through 10","21.34","37.4","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","25.44","53","","173.31","173.31","173.31","1 through 10","21.34","37.4","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","30.00","62.5","","26.48","26.48","26.48","1 through 10","21.34","37.4","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.34","44.45","","127.34","127.34","127.34","1 through 10","21.34","37.4","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","WELLPOINT [1015]","HB CH WELLPOINT","37.40","77.91","","99.24","60.15","134.68","19","21.34","37.4","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","48.00","36.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","28.46","59.3","","59.44","59.44","59.44","1 through 10","24","37.66","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","48.00","36.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","37.66","78.45","","239.87","239.87","239.87","1 through 10","24","37.66","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","48.00","36.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.66","78.45","","77.27","46.21","95.91","26","24","37.66","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","52.78","35.48","309.60","1 through 10","20","35.06","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23.85","53","","173.31","173.31","173.31","1 through 10","20","35.06","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28.13","62.5","","26.48","26.48","26.48","1 through 10","20","35.06","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.00","44.45","","127.34","127.34","127.34","1 through 10","20","35.06","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","WELLPOINT [1015]","HB CH WELLPOINT","35.06","77.91","","99.24","60.15","134.68","19","20","35.06","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","45.00","33.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.69","59.3","","59.44","59.44","59.44","1 through 10","22.5","35.3","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","45.00","33.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","239.87","239.87","239.87","1 through 10","22.5","35.3","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","77.27","46.21","95.91","26","22.5","35.3","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","52.78","35.48","309.60","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","173.31","173.31","173.31","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","26.48","26.48","26.48","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","127.34","127.34","127.34","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","99.24","60.15","134.68","19","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","59.44","59.44","59.44","1 through 10","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","239.87","239.87","239.87","1 through 10","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","77.27","46.21","95.91","26","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","52.78","35.48","309.60","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","173.31","173.31","173.31","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","26.48","26.48","26.48","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","127.34","127.34","127.34","1 through 10","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","99.24","60.15","134.68","19","220.03","385.65","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","59.44","59.44","59.44","1 through 10","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","239.87","239.87","239.87","1 through 10","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","77.27","46.21","95.91","26","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","AETNA [1001]","HB CH AETNA HMO / PPO","72.58","58.3","","52.78","35.48","309.60","1 through 10","55.34","97","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.99","53","","173.31","173.31","173.31","1 through 10","55.34","97","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","77.81","62.5","","26.48","26.48","26.48","1 through 10","55.34","97","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.34","44.45","","127.34","127.34","127.34","1 through 10","55.34","97","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","WELLPOINT [1015]","HB CH WELLPOINT","97.00","77.91","","99.24","60.15","134.68","19","55.34","97","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.50","93.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.83","59.3","","59.44","59.44","59.44","1 through 10","62.25","97.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.50","93.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","97.67","78.45","","239.87","239.87","239.87","1 through 10","62.25","97.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.50","93.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.67","78.45","","77.27","46.21","95.91","26","62.25","97.67","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","52.78","35.48","309.60","1 through 10","29.34","51.42","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.98","53","","173.31","173.31","173.31","1 through 10","29.34","51.42","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","41.25","62.5","","26.48","26.48","26.48","1 through 10","29.34","51.42","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.34","44.45","","127.34","127.34","127.34","1 through 10","29.34","51.42","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB CH WELLPOINT","51.42","77.91","","99.24","60.15","134.68","19","29.34","51.42","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","59.44","59.44","59.44","1 through 10","33","51.78","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","239.87","239.87","239.87","1 through 10","33","51.78","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","77.27","46.21","95.91","26","33","51.78","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","52.78","35.48","309.60","1 through 10","100.01","175.3","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","173.31","173.31","173.31","1 through 10","100.01","175.3","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","140.63","62.5","","26.48","26.48","26.48","1 through 10","100.01","175.3","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","127.34","127.34","127.34","1 through 10","100.01","175.3","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","99.24","60.15","134.68","19","100.01","175.3","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","59.44","59.44","59.44","1 through 10","112.5","176.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","239.87","239.87","239.87","1 through 10","112.5","176.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE WHISPER MS 3CM 300CM.014IN CORONARY STRAIGHT TIP S/S POLYMER HYDROPHILIC","SUP-ITM-10006874","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","77.27","46.21","95.91","26","112.5","176.51","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","AETNA [1001]","HB CH AETNA HMO / PPO","307.12","58.3","","52.78","35.48","309.60","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","279.20","53","","173.31","173.31","173.31","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","329.25","62.5","","26.48","26.48","26.48","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.16","44.45","","127.34","127.34","127.34","1 through 10","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.80","395.10","WELLPOINT [1015]","HB CH WELLPOINT","410.43","77.91","","99.24","60.15","134.68","19","234.16","410.43","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","312.39","59.3","","59.44","59.44","59.44","1 through 10","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","413.27","78.45","","239.87","239.87","239.87","1 through 10","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE HYDRA JAG .035IN 450CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210623","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.80","395.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","413.27","78.45","","77.27","46.21","95.91","26","263.4","413.27","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","52.78","35.48","309.60","1 through 10","138.68","243.08","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","173.31","173.31","173.31","1 through 10","138.68","243.08","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","195.00","62.5","","26.48","26.48","26.48","1 through 10","138.68","243.08","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","127.34","127.34","127.34","1 through 10","138.68","243.08","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","99.24","60.15","134.68","19","138.68","243.08","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","59.44","59.44","59.44","1 through 10","156","244.76","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","239.87","239.87","239.87","1 through 10","156","244.76","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","77.27","46.21","95.91","26","156","244.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","AETNA [1001]","HB CH AETNA HMO / PPO","31.34","58.3","","52.78","35.48","309.60","1 through 10","23.9","41.88","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.49","53","","173.31","173.31","173.31","1 through 10","23.9","41.88","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33.60","62.5","","26.48","26.48","26.48","1 through 10","23.9","41.88","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.90","44.45","","127.34","127.34","127.34","1 through 10","23.9","41.88","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","WELLPOINT [1015]","HB CH WELLPOINT","41.88","77.91","","99.24","60.15","134.68","19","23.9","41.88","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","53.76","40.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.88","59.3","","59.44","59.44","59.44","1 through 10","26.88","42.17","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","239.87","239.87","239.87","1 through 10","26.88","42.17","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","77.27","46.21","95.91","26","26.88","42.17","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","525.30","393.97","AETNA [1001]","HB CH AETNA HMO / PPO","306.25","58.3","","52.78","35.48","309.60","1 through 10","233.5","409.26","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","525.30","393.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","278.41","53","","173.31","173.31","173.31","1 through 10","233.5","409.26","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","525.30","393.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","328.31","62.5","","26.48","26.48","26.48","1 through 10","233.5","409.26","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","525.30","393.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.50","44.45","","127.34","127.34","127.34","1 through 10","233.5","409.26","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","525.30","393.97","WELLPOINT [1015]","HB CH WELLPOINT","409.26","77.91","","99.24","60.15","134.68","19","233.5","409.26","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","525.30","393.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.50","59.3","","59.44","59.44","59.44","1 through 10","262.65","412.1","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","525.30","393.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","412.10","78.45","","239.87","239.87","239.87","1 through 10","262.65","412.1","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","525.30","393.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","412.10","78.45","","77.27","46.21","95.91","26","262.65","412.1","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","AETNA [1001]","HB CH AETNA HMO / PPO","100.74","58.3","","52.78","35.48","309.60","1 through 10","76.81","134.63","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.58","53","","173.31","173.31","173.31","1 through 10","76.81","134.63","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","108.00","62.5","","26.48","26.48","26.48","1 through 10","76.81","134.63","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.81","44.45","","127.34","127.34","127.34","1 through 10","76.81","134.63","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","WELLPOINT [1015]","HB CH WELLPOINT","134.63","77.91","","99.24","60.15","134.68","19","76.81","134.63","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.80","129.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.47","59.3","","59.44","59.44","59.44","1 through 10","86.4","135.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.80","129.60","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","135.56","78.45","","239.87","239.87","239.87","1 through 10","86.4","135.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.80","129.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.56","78.45","","77.27","46.21","95.91","26","86.4","135.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","AETNA [1001]","HB CH AETNA HMO / PPO","83.48","58.3","","52.78","35.48","309.60","1 through 10","63.65","111.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.89","53","","173.31","173.31","173.31","1 through 10","63.65","111.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","89.49","62.5","","26.48","26.48","26.48","1 through 10","63.65","111.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.65","44.45","","127.34","127.34","127.34","1 through 10","63.65","111.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","WELLPOINT [1015]","HB CH WELLPOINT","111.56","77.91","","99.24","60.15","134.68","19","63.65","111.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.19","107.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.91","59.3","","59.44","59.44","59.44","1 through 10","71.6","112.33","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","112.33","78.45","","239.87","239.87","239.87","1 through 10","71.6","112.33","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.19","107.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.33","78.45","","77.27","46.21","95.91","26","71.6","112.33","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","AETNA [1001]","HB CH AETNA HMO / PPO","516.81","58.3","","52.78","35.48","309.60","1 through 10","394.04","690.65","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.83","53","","173.31","173.31","173.31","1 through 10","394.04","690.65","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","554.04","62.5","","26.48","26.48","26.48","1 through 10","394.04","690.65","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.04","44.45","","127.34","127.34","127.34","1 through 10","394.04","690.65","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","WELLPOINT [1015]","HB CH WELLPOINT","690.65","77.91","","99.24","60.15","134.68","19","394.04","690.65","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","886.47","664.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","525.68","59.3","","59.44","59.44","59.44","1 through 10","443.24","695.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","886.47","664.85","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","695.44","78.45","","239.87","239.87","239.87","1 through 10","443.24","695.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","886.47","664.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","695.44","78.45","","77.27","46.21","95.91","26","443.24","695.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","209.79","157.34","AETNA [1001]","HB CH AETNA HMO / PPO","122.31","58.3","","52.78","35.48","309.60","1 through 10","93.25","163.45","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","209.79","157.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","111.19","53","","173.31","173.31","173.31","1 through 10","93.25","163.45","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","209.79","157.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","131.12","62.5","","26.48","26.48","26.48","1 through 10","93.25","163.45","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","209.79","157.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.25","44.45","","127.34","127.34","127.34","1 through 10","93.25","163.45","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","209.79","157.34","WELLPOINT [1015]","HB CH WELLPOINT","163.45","77.91","","99.24","60.15","134.68","19","93.25","163.45","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","209.79","157.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.41","59.3","","59.44","59.44","59.44","1 through 10","104.9","164.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","209.79","157.34","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","164.58","78.45","","239.87","239.87","239.87","1 through 10","104.9","164.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","209.79","157.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.58","78.45","","77.27","46.21","95.91","26","104.9","164.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","AETNA [1001]","HB CH AETNA HMO / PPO","380.11","58.3","","52.78","35.48","309.60","1 through 10","289.81","507.97","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.55","53","","173.31","173.31","173.31","1 through 10","289.81","507.97","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","407.49","62.5","","26.48","26.48","26.48","1 through 10","289.81","507.97","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.81","44.45","","127.34","127.34","127.34","1 through 10","289.81","507.97","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","WELLPOINT [1015]","HB CH WELLPOINT","507.97","77.91","","99.24","60.15","134.68","19","289.81","507.97","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","651.99","488.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.63","59.3","","59.44","59.44","59.44","1 through 10","326","511.49","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","239.87","239.87","239.87","1 through 10","326","511.49","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","77.27","46.21","95.91","26","326","511.49","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","AETNA [1001]","HB CH AETNA HMO / PPO","556.13","58.3","","52.78","35.48","309.60","1 through 10","424.01","743.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.57","53","","173.31","173.31","173.31","1 through 10","424.01","743.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","596.19","62.5","","26.48","26.48","26.48","1 through 10","424.01","743.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.01","44.45","","127.34","127.34","127.34","1 through 10","424.01","743.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","WELLPOINT [1015]","HB CH WELLPOINT","743.19","77.91","","99.24","60.15","134.68","19","424.01","743.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","953.91","715.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","565.67","59.3","","59.44","59.44","59.44","1 through 10","476.96","748.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","748.34","78.45","","239.87","239.87","239.87","1 through 10","476.96","748.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","953.91","715.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.34","78.45","","77.27","46.21","95.91","26","476.96","748.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","AETNA [1001]","HB CH AETNA HMO / PPO","124.90","58.3","","52.78","35.48","309.60","1 through 10","95.23","166.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","113.54","53","","173.31","173.31","173.31","1 through 10","95.23","166.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","133.89","62.5","","26.48","26.48","26.48","1 through 10","95.23","166.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","95.23","44.45","","127.34","127.34","127.34","1 through 10","95.23","166.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","WELLPOINT [1015]","HB CH WELLPOINT","166.91","77.91","","99.24","60.15","134.68","19","95.23","166.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","214.23","160.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","127.04","59.3","","59.44","59.44","59.44","1 through 10","107.12","168.06","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","214.23","160.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","168.06","78.45","","239.87","239.87","239.87","1 through 10","107.12","168.06","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","214.23","160.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","168.06","78.45","","77.27","46.21","95.91","26","107.12","168.06","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","52.78","35.48","309.60","1 through 10","66.68","116.87","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","173.31","173.31","173.31","1 through 10","66.68","116.87","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","26.48","26.48","26.48","1 through 10","66.68","116.87","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","127.34","127.34","127.34","1 through 10","66.68","116.87","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","99.24","60.15","134.68","19","66.68","116.87","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","59.44","59.44","59.44","1 through 10","75","117.68","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","239.87","239.87","239.87","1 through 10","75","117.68","percent of total billed charges",""
"GUIDEWIRE SAFEGUIDE 210CM MARKED SPRING TIP CS/6EA","SUP-ITM-10267939","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","77.27","46.21","95.91","26","75","117.68","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","AETNA [1001]","HB CH AETNA HMO / PPO","111.79","58.3","","52.78","35.48","309.60","1 through 10","85.23","149.39","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","101.63","53","","173.31","173.31","173.31","1 through 10","85.23","149.39","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","119.84","62.5","","26.48","26.48","26.48","1 through 10","85.23","149.39","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.23","44.45","","127.34","127.34","127.34","1 through 10","85.23","149.39","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","WELLPOINT [1015]","HB CH WELLPOINT","149.39","77.91","","99.24","60.15","134.68","19","85.23","149.39","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","191.75","143.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.71","59.3","","59.44","59.44","59.44","1 through 10","95.88","150.43","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","191.75","143.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","150.43","78.45","","239.87","239.87","239.87","1 through 10","95.88","150.43","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","191.75","143.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.43","78.45","","77.27","46.21","95.91","26","95.88","150.43","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","52.78","35.48","309.60","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","173.31","173.31","173.31","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","26.48","26.48","26.48","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","127.34","127.34","127.34","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","99.24","60.15","134.68","19","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","59.44","59.44","59.44","1 through 10","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","239.87","239.87","239.87","1 through 10","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER BLUNT TIP 2 MIS","SUP-ITM-10025484","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","77.27","46.21","95.91","26","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","AETNA [1001]","HB CH AETNA HMO / PPO","61.20","58.3","","52.78","35.48","309.60","1 through 10","46.66","81.78","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.63","53","","173.31","173.31","173.31","1 through 10","46.66","81.78","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.61","62.5","","26.48","26.48","26.48","1 through 10","46.66","81.78","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.66","44.45","","127.34","127.34","127.34","1 through 10","46.66","81.78","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","WELLPOINT [1015]","HB CH WELLPOINT","81.78","77.91","","99.24","60.15","134.68","19","46.66","81.78","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.25","59.3","","59.44","59.44","59.44","1 through 10","52.49","82.35","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.35","78.45","","239.87","239.87","239.87","1 through 10","52.49","82.35","percent of total billed charges",""
"GUIDEWIRE TORQ-FLEX 8CM 60CM .018IN 0CM STRAIGHT TIP S/S AUSTRALIAN MODIFICATION IMAGING HI TORQUE HEPARIN ADULT","SUP-ITM-10028566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.35","78.45","","77.27","46.21","95.91","26","52.49","82.35","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","both","","","555.00","416.25","AETNA [1001]","HB CH AETNA HMO / PPO","323.57","58.3","","52.78","35.48","309.60","1 through 10","246.7","432.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","both","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.15","53","","173.31","173.31","173.31","1 through 10","246.7","432.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","346.88","62.5","","26.48","26.48","26.48","1 through 10","246.7","432.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","both","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.70","44.45","","127.34","127.34","127.34","1 through 10","246.7","432.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","both","","","555.00","416.25","WELLPOINT [1015]","HB CH WELLPOINT","432.40","77.91","","99.24","60.15","134.68","19","246.7","432.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","555.00","416.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.12","59.3","","59.44","59.44","59.44","1 through 10","277.5","435.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","239.87","239.87","239.87","1 through 10","277.5","435.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .021IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10011061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","77.27","46.21","95.91","26","277.5","435.4","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1044.00","783.00","AETNA [1001]","HB CH AETNA HMO / PPO","608.65","58.3","","52.78","35.48","309.60","1 through 10","464.06","813.38","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1044.00","783.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","553.32","53","","173.31","173.31","173.31","1 through 10","464.06","813.38","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1044.00","783.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","652.50","62.5","","26.48","26.48","26.48","1 through 10","464.06","813.38","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1044.00","783.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.06","44.45","","127.34","127.34","127.34","1 through 10","464.06","813.38","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1044.00","783.00","WELLPOINT [1015]","HB CH WELLPOINT","813.38","77.91","","99.24","60.15","134.68","19","464.06","813.38","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1044.00","783.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","619.09","59.3","","59.44","59.44","59.44","1 through 10","522","819.02","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1044.00","783.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","819.02","78.45","","239.87","239.87","239.87","1 through 10","522","819.02","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1044.00","783.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","819.02","78.45","","77.27","46.21","95.91","26","522","819.02","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","AETNA [1001]","HB CH AETNA HMO / PPO","90.25","58.3","","52.78","35.48","309.60","1 through 10","68.81","120.6","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.04","53","","173.31","173.31","173.31","1 through 10","68.81","120.6","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","96.75","62.5","","26.48","26.48","26.48","1 through 10","68.81","120.6","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.81","44.45","","127.34","127.34","127.34","1 through 10","68.81","120.6","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","WELLPOINT [1015]","HB CH WELLPOINT","120.60","77.91","","99.24","60.15","134.68","19","68.81","120.6","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","154.80","116.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.80","59.3","","59.44","59.44","59.44","1 through 10","77.4","121.44","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","154.80","116.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","121.44","78.45","","239.87","239.87","239.87","1 through 10","77.4","121.44","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","154.80","116.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.44","78.45","","77.27","46.21","95.91","26","77.4","121.44","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","AETNA [1001]","HB CH AETNA HMO / PPO","87.54","58.3","","52.78","35.48","309.60","1 through 10","66.75","116.99","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.58","53","","173.31","173.31","173.31","1 through 10","66.75","116.99","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.85","62.5","","26.48","26.48","26.48","1 through 10","66.75","116.99","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.75","44.45","","127.34","127.34","127.34","1 through 10","66.75","116.99","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","WELLPOINT [1015]","HB CH WELLPOINT","116.99","77.91","","99.24","60.15","134.68","19","66.75","116.99","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.16","112.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.04","59.3","","59.44","59.44","59.44","1 through 10","75.08","117.8","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.16","112.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.80","78.45","","239.87","239.87","239.87","1 through 10","75.08","117.8","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.16","112.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.80","78.45","","77.27","46.21","95.91","26","75.08","117.8","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","AETNA [1001]","HB CH AETNA HMO / PPO","208.59","58.3","","52.78","35.48","309.60","1 through 10","159.03","278.75","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","189.62","53","","173.31","173.31","173.31","1 through 10","159.03","278.75","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","223.61","62.5","","26.48","26.48","26.48","1 through 10","159.03","278.75","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.03","44.45","","127.34","127.34","127.34","1 through 10","159.03","278.75","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","WELLPOINT [1015]","HB CH WELLPOINT","278.75","77.91","","99.24","60.15","134.68","19","159.03","278.75","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","357.78","268.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.16","59.3","","59.44","59.44","59.44","1 through 10","178.89","280.68","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","357.78","268.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","280.68","78.45","","239.87","239.87","239.87","1 through 10","178.89","280.68","percent of total billed charges",""
"GUIDEWIRE UROLOGY .025IN 260CM GLIDEWIRE RADIOFOCUS STRAIGHT BX/5EA","SUP-ITM-10118216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","357.78","268.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","280.68","78.45","","77.27","46.21","95.91","26","178.89","280.68","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","104.46","78.34","WELLPOINT [1015]","HB CH WELLPOINT","81.38","77.91","","582.67","582.67","582.67","1 through 10","46.43","81.38","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","104.46","78.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.95","78.45","","394.74","331.66","1115.07","1 through 10","52.23","81.95","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","both","","","119.19","89.39","AETNA [1001]","HB CH AETNA HMO / PPO","69.49","58.3","","52.78","35.48","309.60","1 through 10","52.98","92.86","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","both","","","119.19","89.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.17","53","","173.31","173.31","173.31","1 through 10","52.98","92.86","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","both","","","119.19","89.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","74.49","62.5","","26.48","26.48","26.48","1 through 10","52.98","92.86","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","both","","","119.19","89.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.98","44.45","","127.34","127.34","127.34","1 through 10","52.98","92.86","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","both","","","119.19","89.39","WELLPOINT [1015]","HB CH WELLPOINT","92.86","77.91","","99.24","60.15","134.68","19","52.98","92.86","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","119.19","89.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.68","59.3","","59.44","59.44","59.44","1 through 10","59.6","93.5","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","119.19","89.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","93.50","78.45","","239.87","239.87","239.87","1 through 10","59.6","93.5","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.0X150CM .038IN STANDARD LUBRIGLIDE COATED FIXED CORE STIFF BODIED STRAIGHT","SUP-ITM-10027249","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","119.19","89.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.50","78.45","","77.27","46.21","95.91","26","59.6","93.5","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.62","124.21","AETNA [1001]","HB CH AETNA HMO / PPO","96.56","58.3","","52.78","35.48","309.60","1 through 10","73.62","129.03","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.62","124.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","87.78","53","","173.31","173.31","173.31","1 through 10","73.62","129.03","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.62","124.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","103.51","62.5","","26.48","26.48","26.48","1 through 10","73.62","129.03","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.62","124.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.62","44.45","","127.34","127.34","127.34","1 through 10","73.62","129.03","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.62","124.21","WELLPOINT [1015]","HB CH WELLPOINT","129.03","77.91","","99.24","60.15","134.68","19","73.62","129.03","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.62","124.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","98.21","59.3","","59.44","59.44","59.44","1 through 10","82.81","129.93","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.62","124.21","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","129.93","78.45","","239.87","239.87","239.87","1 through 10","82.81","129.93","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN GLIDEWIRE HYDROPHILIC COATED STANDARD STRAIGHT TAPERED TIP PK/5EA","SUP-ITM-10115551","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.62","124.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.93","78.45","","77.27","46.21","95.91","26","82.81","129.93","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","both","","","252.00","189.00","AETNA [1001]","HB CH AETNA HMO / PPO","146.92","58.3","","52.78","35.48","309.60","1 through 10","112.01","196.33","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","both","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","133.56","53","","173.31","173.31","173.31","1 through 10","112.01","196.33","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","157.50","62.5","","26.48","26.48","26.48","1 through 10","112.01","196.33","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.01","44.45","","127.34","127.34","127.34","1 through 10","112.01","196.33","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB CH WELLPOINT","196.33","77.91","","99.24","60.15","134.68","19","112.01","196.33","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","252.00","189.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","149.44","59.3","","59.44","59.44","59.44","1 through 10","126","197.69","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","197.69","78.45","","239.87","239.87","239.87","1 through 10","126","197.69","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 300CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008601","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","197.69","78.45","","77.27","46.21","95.91","26","126","197.69","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.40","46.80","AETNA [1001]","HB CH AETNA HMO / PPO","36.38","58.3","","52.78","35.48","309.60","1 through 10","27.74","48.62","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.40","46.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","33.07","53","","173.31","173.31","173.31","1 through 10","27.74","48.62","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.40","46.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","39.00","62.5","","26.48","26.48","26.48","1 through 10","27.74","48.62","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.40","46.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.74","44.45","","127.34","127.34","127.34","1 through 10","27.74","48.62","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.40","46.80","WELLPOINT [1015]","HB CH WELLPOINT","48.62","77.91","","99.24","60.15","134.68","19","27.74","48.62","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.40","46.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.00","59.3","","59.44","59.44","59.44","1 through 10","31.2","48.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.40","46.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","48.95","78.45","","239.87","239.87","239.87","1 through 10","31.2","48.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.40","46.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.95","78.45","","77.27","46.21","95.91","26","31.2","48.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","52.78","35.48","309.60","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","173.31","173.31","173.31","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","26.48","26.48","26.48","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","127.34","127.34","127.34","1 through 10","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","99.24","60.15","134.68","19","60.01","105.18","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","59.44","59.44","59.44","1 through 10","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","239.87","239.87","239.87","1 through 10","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE VASCULAR .062INX51CM BLUNT TIP","SUP-ITM-10088439","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","77.27","46.21","95.91","26","67.5","105.91","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","41.37","31.03","AETNA [1001]","HB CH AETNA HMO / PPO","24.12","58.3","","52.78","35.48","309.60","1 through 10","18.39","32.23","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","41.37","31.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","21.93","53","","173.31","173.31","173.31","1 through 10","18.39","32.23","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","41.37","31.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25.86","62.5","","26.48","26.48","26.48","1 through 10","18.39","32.23","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","41.37","31.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.39","44.45","","127.34","127.34","127.34","1 through 10","18.39","32.23","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","41.37","31.03","WELLPOINT [1015]","HB CH WELLPOINT","32.23","77.91","","99.24","60.15","134.68","19","18.39","32.23","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","41.37","31.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.53","59.3","","59.44","59.44","59.44","1 through 10","20.69","32.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","41.37","31.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","32.45","78.45","","239.87","239.87","239.87","1 through 10","20.69","32.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","41.37","31.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.45","78.45","","77.27","46.21","95.91","26","20.69","32.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.97","35.98","AETNA [1001]","HB CH AETNA HMO / PPO","27.97","58.3","","52.78","35.48","309.60","1 through 10","21.32","37.37","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.97","35.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","25.42","53","","173.31","173.31","173.31","1 through 10","21.32","37.37","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.97","35.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29.98","62.5","","26.48","26.48","26.48","1 through 10","21.32","37.37","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.97","35.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.32","44.45","","127.34","127.34","127.34","1 through 10","21.32","37.37","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.97","35.98","WELLPOINT [1015]","HB CH WELLPOINT","37.37","77.91","","99.24","60.15","134.68","19","21.32","37.37","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.97","35.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","28.45","59.3","","59.44","59.44","59.44","1 through 10","23.99","37.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.97","35.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","37.63","78.45","","239.87","239.87","239.87","1 through 10","23.99","37.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .025IN STRAIGHT TIP PTFE COATED FIXED CORE S/S","SUP-ITM-10000058","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.97","35.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.63","78.45","","77.27","46.21","95.91","26","23.99","37.63","percent of total billed charges",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","56351.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21717.84","","Standard inlier is a Case rate ($21,717.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,082.93) for the length of stay and the standard reimbursement.","21717.83","21717.83","21717.83","1 through 10","7730.53","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","56351.84","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16417.2342","","Fee schedule rate ($20,352.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16417.2342","16417.24","16417.24","1 through 10","7730.53","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","56351.84","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17238.0119","","Fee schedule rate ($21,370.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17238.0119","17238.00","17238.00","1 through 10","7730.53","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","50927.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16417.2342","","Fee schedule rate ($20,352.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16417.2342","20353.00","20353.00","1 through 10","7730.53","33582.13","case rate",""
"Gynecologic Procedures Without Malignancy,MINOR","513","DRG","","","","","","","","inpatient","","","51243.59","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24669.69","","Standard inlier is a Case rate ($24,669.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,207, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,501.76) for the length of stay and the standard reimbursement.","23548.34","23548.34","23548.34","1 through 10","7963.43","32543.87","case rate",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","42951.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29696.85","","Standard inlier is a Case rate ($29,696.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,010, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,215.34) for the length of stay and the standard reimbursement.","28346.99","28346.99","28346.99","1 through 10","7963.43","32543.87","case rate",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","15.52","93.46","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","10.07","65.11","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","62.27","36.90","62.27","1 through 10","10.07","65.11","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","AETNA [1001]","HB CH AETNA HMO / PPO","2418.77","58.3","","1530.90","1160.93","1884.08","89","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2198.89","53","","5253.92","5253.92","5253.92","1 through 10","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2406.33","58","","12181.47","12181.47","12181.47","1 through 10","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2593.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1844.16","44.45","","1910.74","891.94","1910.74","1 through 10","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4148.84","3111.63","WELLPOINT [1015]","HB CH WELLPOINT","3232.36","77.91","","1829.79","1561.50","2617.12","88","1844.16","3232.36","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4148.84","3111.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","2460.26","59.3","","1359.46","1201.30","1689.00","61","2074.42","3254.76","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4148.84","3111.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2460.26","59.3","","1718.92","1718.92","1718.92","1 through 10","2074.42","3254.76","percent of total billed charges",""
"HAMMERTOE IMPLANT 10DEG MD JNT TOETAC","SUP-ITM-10232492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4148.84","3111.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3254.76","78.45","","1910.74","1019.06","2344.84","74","2074.42","3254.76","percent of total billed charges",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","39252.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19415.88","","Standard inlier is a Case rate ($19,415.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,756.16) for the length of stay and the standard reimbursement.","19415.88","19415.88","19415.88","1 through 10","8492.24","72803.73","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","39252.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20856.53","","Standard inlier is a Case rate ($20,856.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,960.50) for the length of stay and the standard reimbursement.","19813.69","19813.69","19813.69","1 through 10","8492.24","72803.73","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","39252.74","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9702.11","","Case rate ($10,452.50). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,882.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5065.09","5065.09","5065.09","1 through 10","8492.24","72803.73","case rate",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","AETNA [1001]","HB CH AETNA HMO / PPO","2155.64","58.3","","464.71","67.87","1012.10","221","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2155.64","58.3","","293.04","293.04","293.04","11","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1959.68","53","","983.89","983.89","983.89","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2144.55","58","","677.18","677.18","677.18","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2310.94","62.5","","46.58","46.58","46.58","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2699.18","73","","747.15","747.15","747.15","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1643.54","44.45","","1141.67","481.21","1141.67","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1643.54","44.45","","76.54","76.54","76.54","1 through 10","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","WELLPOINT [1015]","HB CH WELLPOINT","2880.72","77.91","","273.64","94.28","1367.51","138","1643.54","2880.72","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2192.62","59.3","","720.78","230.14","2010.94","427","1848.75","2900.69","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2192.62","59.3","","344.45","344.45","344.45","1 through 10","1848.75","2900.69","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2900.69","78.45","","1120.13","1120.13","1120.13","1 through 10","1848.75","2900.69","percent of total billed charges",""
"HAND IMPLANT 4.0MMX25CM PROSTHESIS TENDON HUNTER FINGER PASSIVE","SUP-ITM-10133910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2900.69","78.45","","456.17","105.33","1284.66","242","1848.75","2900.69","percent of total billed charges",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/McC","514","MS-DRG","","","","","","","","inpatient","","","31648.14","23736.10","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9122.83","","Case rate ($8,857.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,098.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,240.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,618.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,180.28. The transfer operating threshold is the transfer adjustment factor * $9,098.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.85. The transfer capital threshold is the transfer adjustment factor * $676.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9133.44","9133.44","9133.44","1 through 10","8679.98","10493.91","other","Inpatient DRG"
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","AETNA [1001]","HB CH AETNA HMO / PPO","1677.29","58.3","","464.71","67.87","1012.10","221","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1677.29","58.3","","293.04","293.04","293.04","11","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1524.81","53","","983.89","983.89","983.89","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1668.66","58","","677.18","677.18","677.18","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1798.13","62.5","","46.58","46.58","46.58","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2100.21","73","","747.15","747.15","747.15","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.83","44.45","","1141.67","481.21","1141.67","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.83","44.45","","76.54","76.54","76.54","1 through 10","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2877.00","2157.75","WELLPOINT [1015]","HB CH WELLPOINT","2241.47","77.91","","273.64","94.28","1367.51","138","1278.83","2241.47","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2877.00","2157.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1706.06","59.3","","720.78","230.14","2010.94","427","1438.5","2257.01","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2877.00","2157.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1706.06","59.3","","344.45","344.45","344.45","1 through 10","1438.5","2257.01","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2877.00","2157.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2257.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1438.5","2257.01","percent of total billed charges",""
"HAND PLATE .8MM 8 HOLE APTUS TITANIUM","SUP-ITM-10146096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2877.00","2157.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2257.01","78.45","","456.17","105.33","1284.66","242","1438.5","2257.01","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","AETNA [1001]","HB CH AETNA HMO / PPO","1264.53","58.3","","464.71","67.87","1012.10","221","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1264.53","58.3","","293.04","293.04","293.04","11","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1149.57","53","","983.89","983.89","983.89","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1258.02","58","","677.18","677.18","677.18","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1355.63","62.5","","46.58","46.58","46.58","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1583.37","73","","747.15","747.15","747.15","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","964.12","44.45","","1141.67","481.21","1141.67","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","964.12","44.45","","76.54","76.54","76.54","1 through 10","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.00","1626.75","WELLPOINT [1015]","HB CH WELLPOINT","1689.87","77.91","","273.64","94.28","1367.51","138","964.12","1689.87","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.00","1626.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1286.22","59.3","","720.78","230.14","2010.94","427","1084.5","1701.58","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.00","1626.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1286.22","59.3","","344.45","344.45","344.45","1 through 10","1084.5","1701.58","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.00","1626.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1701.58","78.45","","1120.13","1120.13","1120.13","1 through 10","1084.5","1701.58","percent of total billed charges",""
"HAND PLATE 0.8MM 10 HOLE FIXATION TRAPEZOIDAL TRILOCK GRID","SUP-ITM-10126703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.00","1626.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1701.58","78.45","","456.17","105.33","1284.66","242","1084.5","1701.58","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","464.71","67.87","1012.10","221","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","293.04","293.04","293.04","11","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","983.89","983.89","983.89","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2338.85","58","","677.18","677.18","677.18","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2520.31","62.5","","46.58","46.58","46.58","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","747.15","747.15","747.15","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1792.45","44.45","","1141.67","481.21","1141.67","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1792.45","44.45","","76.54","76.54","76.54","1 through 10","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","273.64","94.28","1367.51","138","1792.45","3141.72","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","720.78","230.14","2010.94","427","2016.25","3163.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2391.27","59.3","","344.45","344.45","344.45","1 through 10","2016.25","3163.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","1120.13","1120.13","1120.13","1 through 10","2016.25","3163.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","456.17","105.33","1284.66","242","2016.25","3163.5","percent of total billed charges",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","","","","inpatient","","","18512.08","13884.06","MEDICARE [2001]","HB NWH MEDICARE","18712.31","","Case rate ($18,712.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,482.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,624.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,242.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,411.78. The transfer operating threshold is the transfer adjustment factor * $17,482.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,300.54. The transfer capital threshold is the transfer adjustment factor * $1,300.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3399.86","3399.86","3399.86","1 through 10","16678.17","20163.54","other","Inpatient DRG"
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","62.94","62.94","62.94","1 through 10","12.33","108.3","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","65.05","65.05","74.14","1 through 10","12.97","89.43","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","85.34","50.57","85.34","13","12.97","89.43","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","AETNA [1001]","HB CH AETNA HMO / PPO","3633.26","58.3","","52.60","33.42","52.60","1932","96.52","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","WELLPOINT [1015]","HB CH WELLPOINT","4855.35","77.91","","77.77","77.77","77.77","240","96.52","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6232.00","4674.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3253.10","52.2","","47.77","47.77","47.77","480","3116","3253.1","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","AETNA [1001]","HB CH AETNA HMO / PPO","5399.75","58.3","","52.60","33.42","52.60","1932","96.52","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","WELLPOINT [1015]","HB CH WELLPOINT","7216.02","77.91","","77.77","77.77","77.77","240","96.52","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9262.00","6946.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4834.76","52.2","","47.77","47.77","47.77","480","4631","4834.76","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","AETNA [1001]","HB CH AETNA HMO / PPO","5398.58","58.3","","52.60","33.42","52.60","1932","96.52","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","WELLPOINT [1015]","HB CH WELLPOINT","7214.47","77.91","","77.77","77.77","77.77","240","96.52","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9260.00","6945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4833.72","52.2","","47.77","47.77","47.77","480","4630","4833.72","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","AETNA [1001]","HB CH AETNA HMO / PPO","6479.46","58.3","","52.60","33.42","52.60","1932","96.52","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","WELLPOINT [1015]","HB CH WELLPOINT","8658.92","77.91","","77.77","77.77","77.77","240","96.52","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11114.00","8335.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5801.51","52.2","","47.77","47.77","47.77","480","5557","5801.51","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","AETNA [1001]","HB CH AETNA HMO / PPO","6749.97","58.3","","52.60","33.42","52.60","1932","96.52","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","WELLPOINT [1015]","HB CH WELLPOINT","9020.42","77.91","","77.77","77.77","77.77","240","96.52","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11578.00","8683.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","6043.72","52.2","","47.77","47.77","47.77","480","5789","6043.72","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","AETNA [1001]","HB CH AETNA HMO / PPO","8100.20","58.3","","52.60","33.42","52.60","1932","96.52","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","WELLPOINT [1015]","HB CH WELLPOINT","10824.82","77.91","","77.77","77.77","77.77","240","96.52","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13894.00","10420.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7252.67","52.2","","47.77","47.77","47.77","480","6947","7252.67","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0300","RC","","","","inpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.80","56","","45.71","45.71","45.71","1 through 10","44.8","56.48","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0300","RC","","","","inpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.48","70.6","","59.97","35.54","59.97","1 through 10","44.8","56.48","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","263","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","78.00","78.00","78.00","1 through 10","11.83","170.56","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","42.86","42.86","44.23","1 through 10","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","TRICARE [160005]","HB NWH TRICARE","44.28","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","78.00","78.00","78.00","1 through 10","11.83","170.56","other","Tricare OPPS"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","59.97","35.54","59.97","1 through 10","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","137.13","238","3.08","108.57","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","35.54","59.97","193","3.08","108.57","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","521.46","391.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.37","53","","163.66","163.66","163.66","1 through 10","231.79","406.27","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","521.46","391.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","325.91","62.5","","97.92","97.92","225.72","1 through 10","231.79","406.27","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","521.46","391.09","WELLPOINT [1015]","HB CH WELLPOINT","406.27","77.91","","243.20","243.20","243.20","1 through 10","231.79","406.27","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","521.46","391.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.09","78.45","","40.36","40.36","40.36","1 through 10","260.73","409.09","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1841.75","53","","163.66","163.66","163.66","1 through 10","1544.64","2707.37","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2171.88","62.5","","97.92","97.92","225.72","1 through 10","1544.64","2707.37","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","3475.00","2606.25","WELLPOINT [1015]","HB CH WELLPOINT","2707.37","77.91","","243.20","243.20","243.20","1 through 10","1544.64","2707.37","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2726.14","78.45","","40.36","40.36","40.36","1 through 10","1737.5","2726.14","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","4523.33","3392.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2397.36","53","","163.66","163.66","163.66","1 through 10","2010.62","3524.13","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","4523.33","3392.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2827.08","62.5","","97.92","97.92","225.72","1 through 10","2010.62","3524.13","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","4523.33","3392.50","WELLPOINT [1015]","HB CH WELLPOINT","3524.13","77.91","","243.20","243.20","243.20","1 through 10","2010.62","3524.13","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4523.33","3392.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3548.55","78.45","","40.36","40.36","40.36","1 through 10","2261.67","3548.55","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","876.16","657.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","687.35","78.45","","680.39","680.39","680.39","1 through 10","438.08","687.35","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","680.39","680.39","680.39","1 through 10","1828.13","2868.33","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","3807.60","2855.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2987.06","78.45","","680.39","680.39","680.39","1 through 10","1903.8","2987.06","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","both","","","363.59","272.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","210.88","58","","183.58","183.58","183.58","1 through 10","161.62","283.27","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","both","","","3336.04","2502.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1934.90","58","","183.58","183.58","183.58","1 through 10","1482.87","2599.11","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","both","","","4980.00","3735.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2888.40","58","","183.58","183.58","183.58","1 through 10","2213.61","3879.92","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","548.04","411.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","429.94","78.45","","166.06","166.06","166.06","1 through 10","274.02","429.94","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","166.06","166.06","166.06","1 through 10","2000","3138","percent of total billed charges",""
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","outpatient","","","262.00","196.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","176.08","172.43","176.08","1 through 10","121.77","263.01","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.91","633.68","688.91","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","774.32","1919.74","per diem",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","686.12","686.12","686.12","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","808.97","792.16","808.97","1 through 10","871","1873.9","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","793.28","793.28","810.09","1 through 10","871","1873.9","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1033.01","59.3","","992.44","992.44","992.44","1 through 10","871","1873.9","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","AETNA [1001]","HB CH AETNA HMO / PPO","2193.83","58.3","","2074.65","2074.65","2074.65","1 through 10","950.62","2931.75","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","980.54","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3083.96","3082.96","3083.96","11","950.62","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","WELLPOINT [1015]","HB CH WELLPOINT","2931.75","77.91","","2881.83","2881.83","2881.83","1 through 10","950.62","2931.75","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","outpatient","","","3763.00","2822.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2231.46","59.3","","2401.53","2401.53","2401.53","1 through 10","1222","2952.07","percent of total billed charges",""
"HC Ewo Rigit Without Joints Custom Tier1","PX-27000485","CDM","L3763","HCPCS","0274","RC","","","","both","","","585.22","438.91","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","371.03","63.4","","388.00","388.00","388.00","1 through 10","310.17","2483.05","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","both","","","23280.56","17460.42","AETNA [1001]","HB CH AETNA HMO / PPO","13572.57","58.3","","41334.30","41334.30","41334.30","1 through 10","12338.7","18137.88","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","23280.56","17460.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","13805.37","59.3","","21359.70","21359.70","21359.70","1 through 10","10348.21","18263.6","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","23280.56","17460.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18263.60","78.45","","28022.76","16606.62","28022.76","1 through 10","10348.21","18263.6","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","both","","","258.36","193.77","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","163.80","63.4","","164.83","164.83","164.83","1 through 10","136.93","1096.15","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","AETNA [1001]","HB CH AETNA HMO / PPO","189.94","58.3","","184.73","184.73","184.73","1 through 10","172.67","676.2","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","WELLPOINT [1015]","HB CH WELLPOINT","253.83","77.91","","256.60","256.60","256.60","1 through 10","172.67","676.2","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","325.80","244.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.07","52.2","","167.79","167.79","167.79","1 through 10","144.82","502.22","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","1 through 10","14.69","169.1","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","202.76","1 through 10","15.46","139.64","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","133.00","133.00","1 through 10","15.46","139.64","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","24081.00","18060.75","MEDICARE [2001]","HB NWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38075.05","38075.05","38075.05","1 through 10","12762.93","39213.34","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","24081.00","18060.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","5934.00","5934.00","5934.00","1 through 10","12762.93","39213.34","per diem",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","24081.00","18060.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","50622.77","50622.77","50622.77","1 through 10","10704","47095.48","other","ASC "
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","24081.00","18060.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","50692.88","50692.88","50692.88","1 through 10","10704","47095.48","other","ASC "
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","AETNA [1001]","HB CH AETNA HMO / PPO","107.91","58.3","","48.90","46.54","48.90","1 through 10","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.10","53","","91.65","91.65","91.65","1 through 10","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","107.35","58","","51.23","51.23","51.23","1 through 10","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","115.68","62.5","","65.12","36.89","65.12","1 through 10","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.12","73","","46.29","46.29","46.29","1 through 10","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","WELLPOINT [1015]","HB CH WELLPOINT","144.20","77.91","","64.65","45.40","120.92","18","82.27","144.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","185.09","138.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.20","78.45","","276.77","63.10","312.43","11","92.55","145.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","AETNA [1001]","HB CH AETNA HMO / PPO","2230.34","58.3","","48.90","46.54","48.90","1 through 10","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2027.58","53","","91.65","91.65","91.65","1 through 10","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2218.87","58","","51.23","51.23","51.23","1 through 10","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2391.02","62.5","","65.12","36.89","65.12","1 through 10","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2792.71","73","","46.29","46.29","46.29","1 through 10","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","WELLPOINT [1015]","HB CH WELLPOINT","2980.55","77.91","","64.65","45.40","120.92","18","1700.49","2980.55","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3825.63","2869.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3001.21","78.45","","276.77","63.10","312.43","11","1912.82","3001.21","percent of total billed charges",""
"HC Mml Flec Flecainide Serum","PX-3002350","CDM","80299","CPT","0300","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","156.75","percent of total billed charges",""
"HC Mml Flec Flecainide Serum","PX-3002350","CDM","80299","CPT","0300","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","125.99","125.99","125.99","1 through 10","14.12","129.44","percent of total billed charges",""
"HC Mml Flec Flecainide Serum","PX-3002350","CDM","80299","CPT","0300","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","165.29","97.95","215.00","1 through 10","14.12","129.44","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","243.82","1 through 10","23.61","209.95","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","165.29","165.29","165.29","1 through 10","23.61","209.95","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","92.83","92.83","92.83","1 through 10","18.62","173.37","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","18.62","173.37","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2126.00","1594.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1040.36","1036.13","1561.70","1 through 10","764.84","1627.62","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2126.00","1594.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1897.09","1897.09","1897.09","1 through 10","1311.96","4373.87","other","ASC "
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","both","","","16762.00","12571.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13205.76","13205.76","13205.76","1 through 10","8702.14","13870.23","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","1248.00","936.00","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","911.04","other","OPPS APC"
"HC Prosthetic Implant Nos T1","PX-27000984","CDM","L8699","HCPCS","0278","RC","","","","outpatient","","","1707.00","1280.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1012.25","59.3","","184.04","184.04","184.04","1 through 10","853.5","1339.14","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","386.00","289.50","AETNA [1001]","HB CH AETNA HMO / PPO","225.04","58.3","","127.91","127.91","127.91","1 through 10","204.58","422.13","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","454.00","340.50","AETNA [1001]","HB CH AETNA HMO / PPO","264.68","58.3","","192.11","192.11","192.11","1 through 10","240.62","431.75","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","454.00","340.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","1 through 10","240.62","431.75","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","454.00","340.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","274.67","60.5","","408.80","408.80","441.00","22","122.71","380.6","percent of total billed charges",""
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","9703.00","7277.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35332.31","35332.31","35332.31","1 through 10","4162.59","39213.34","other","OPPS APC"
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3932.19","2949.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3084.80","78.45","","7551.15","7551.15","7551.15","1 through 10","1966.1","3084.8","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6215.94","4661.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.40","78.45","","7551.15","7551.15","7551.15","1 through 10","3107.97","4876.4","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","AETNA [1001]","HB CH AETNA HMO / PPO","167.34","58.3","","188.13","151.57","188.13","1 through 10","127.59","223.63","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","152.13","53","","175.85","175.85","175.85","1 through 10","127.59","223.63","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.59","44.45","","255.09","255.09","255.09","1 through 10","127.59","223.63","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","WELLPOINT [1015]","HB CH WELLPOINT","223.63","77.91","","261.33","130.66","261.33","1 through 10","127.59","223.63","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","287.04","215.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.21","59.3","","194.43","189.79","327.42","11","143.52","225.18","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","287.04","215.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.18","78.45","","255.09","151.17","255.09","1 through 10","143.52","225.18","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier1","PX-27000208","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.66","245.74","WELLPOINT [1015]","HB CH WELLPOINT","255.28","77.91","","317.80","317.80","317.80","1 through 10","145.64","255.28","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier3","PX-27000209","CDM","C2625","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","317.80","317.80","317.80","1 through 10","2222.5","3895.5","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","1936.60","1452.45","AETNA [1001]","HB CH AETNA HMO / PPO","1129.04","58.3","","1903.50","1903.50","1903.50","1 through 10","860.82","1508.81","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","1936.60","1452.45","WELLPOINT [1015]","HB CH WELLPOINT","1508.81","77.91","","194.63","194.63","194.63","1 through 10","860.82","1508.81","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1936.60","1452.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1148.40","59.3","","144.81","144.81","144.81","1 through 10","968.3","1519.26","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","3700.52","2775.39","AETNA [1001]","HB CH AETNA HMO / PPO","2157.40","58.3","","1903.50","1903.50","1903.50","1 through 10","1644.88","2883.08","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","3700.52","2775.39","WELLPOINT [1015]","HB CH WELLPOINT","2883.08","77.91","","194.63","194.63","194.63","1 through 10","1644.88","2883.08","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3700.52","2775.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2194.41","59.3","","144.81","144.81","144.81","1 through 10","1850.26","2903.06","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","4136.40","3102.30","AETNA [1001]","HB CH AETNA HMO / PPO","2411.52","58.3","","1903.50","1903.50","1903.50","1 through 10","1838.63","3222.67","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","4136.40","3102.30","WELLPOINT [1015]","HB CH WELLPOINT","3222.67","77.91","","194.63","194.63","194.63","1 through 10","1838.63","3222.67","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4136.40","3102.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","2452.89","59.3","","144.81","144.81","144.81","1 through 10","2068.2","3245.01","percent of total billed charges",""
"HC Testosterone; Bioavailable, Direct Measurement (Eg, Diff Precipitation)","PX-30003343","CDM","84410","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","445.82","445.82","445.82","1 through 10","155.92","334.2","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","388.65","291.49","AETNA [1001]","HB CH AETNA HMO / PPO","226.58","58.3","","220.36","220.36","220.36","1 through 10","205.98","1649","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","388.65","291.49","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","246.40","63.4","","247.96","247.96","247.96","1 through 10","205.98","1649","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","230.47","59.3","","227.75","227.75","227.75","1 through 10","172.75","1094.8","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","224.25","57.7","","234.36","221.92","681.19","1 through 10","172.75","1094.8","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","235.13","60.5","","470.66","246.02","470.66","1 through 10","172.75","1094.8","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0300","RC","","","","inpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.44","56","","99.03","99.03","99.03","1 through 10","97.44","122.84","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0300","RC","","","","inpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.84","70.6","","77.00","77.00","77.00","1 through 10","97.44","122.84","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","AETNA [1001]","HB CH AETNA HMO / PPO","101.44","58.3","","95.82","95.82","95.82","383","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127.02","73","","27.23","18.06","99.03","1 through 10","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","TRICARE [160005]","HB NWH TRICARE","165.30","95","","18.14","17.23","18.14","1 through 10","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","165.30","95","","15.05","15.05","15.05","1 through 10","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.34","44.45","","77.00","77.00","129.93","1 through 10","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.34","44.45","","129.93","129.93","129.93","1 through 10","14.75","165.3","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.18","59.3","","99.03","99.03","99.03","271","15.53","136.5","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.50","78.45","","129.93","77.00","129.93","262","15.53","136.5","percent of total billed charges",""
"Hcpr Psych - New Pt - Level 1 Visit","PX-96100040","CDM","99201","CPT","0961","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","40.21","40.21","40.21","1 through 10","43.2","344","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","AETNA [1001]","HB CH AETNA HMO / PPO","233.78","58.3","","127.91","127.91","127.91","1 through 10","212.53","422.13","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","AETNA [1001]","HB CH AETNA HMO / PPO","345.72","58.3","","192.11","192.11","192.11","1 through 10","314.29","563.35","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","1 through 10","314.29","563.35","other","OPPS APC"
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1530.90","1160.93","1884.08","89","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","5253.92","5253.92","5253.92","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","12181.47","12181.47","12181.47","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1910.74","891.94","1910.74","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","1829.79","1561.50","2617.12","88","1610.87","2823.46","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1359.46","1201.30","1689.00","61","1812","2843.03","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1718.92","1718.92","1718.92","1 through 10","1812","2843.03","percent of total billed charges",""
"HEAD GLENOID 32MM -4MM OFFSET REVERSE RSP GLENOID HEAD RETAINING SCREW","SUP-ITM-10207515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1910.74","1019.06","2344.84","74","1812","2843.03","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","AETNA [1001]","HB CH AETNA HMO / PPO","3587.88","58.3","","1530.90","1160.93","1884.08","89","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3261.70","53","","5253.92","5253.92","5253.92","1 through 10","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3569.41","58","","12181.47","12181.47","12181.47","1 through 10","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3846.35","62.5","","1350.68","1350.68","1350.68","1 through 10","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2735.52","44.45","","1910.74","891.94","1910.74","1 through 10","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","6154.16","4615.62","WELLPOINT [1015]","HB CH WELLPOINT","4794.71","77.91","","1829.79","1561.50","2617.12","88","2735.52","4794.71","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6154.16","4615.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","3649.42","59.3","","1359.46","1201.30","1689.00","61","3077.08","4827.94","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6154.16","4615.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3649.42","59.3","","1718.92","1718.92","1718.92","1 through 10","3077.08","4827.94","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6154.16","4615.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4827.94","78.45","","1910.74","1019.06","2344.84","74","3077.08","4827.94","percent of total billed charges",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MINOR","055","DRG","","","","","","","","inpatient","","","22264.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16074.27","","Standard inlier is a Case rate ($16,074.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,281.68) for the length of stay and the standard reimbursement.","15343.62","15343.62","15343.62","1 through 10","5417.1","30125.57","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MODERATE","055","DRG","","","","","","","","inpatient","","","31023.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22641.97","","Standard inlier is a Case rate ($22,641.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,272, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,213.93) for the length of stay and the standard reimbursement.","22641.97","22641.97","24803.35","1 through 10","5417.1","30125.57","case rate",""
"Headaches With McC","102","MS-DRG","","","","","","","","inpatient","","","25270.29","18952.72","MEDICARE [2001]","HB NWH MEDICARE","10677.91","","Case rate ($10,677.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,976.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,118.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,684.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,935.79. The transfer operating threshold is the transfer adjustment factor * $9,976.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $742.13. The transfer capital threshold is the transfer adjustment factor * $742.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11086.38","11086.38","11086.38","1 through 10","9517.15","11506.04","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","29723.77","22292.83","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7245.64","","Case rate ($7,245.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,443.24, add-ons for qualifying new technology services are included. If operating cost exceeds $52,585.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,495.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,691.94. The transfer operating threshold is the transfer adjustment factor * $7,443.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.70. The transfer capital threshold is the transfer adjustment factor * $553.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7333.88","7333.88","7333.88","1 through 10","7100.73","8407.6278","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","29723.77","22292.83","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5928.81","5928.81","5928.81","1 through 10","7100.73","8407.6278","case rate",""
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","29723.77","22292.83","HUMANA [1012]","HB NWH MEDICARE","7245.64","","Case rate ($7,245.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,443.24, add-ons for qualifying new technology services are included. If operating cost exceeds $52,585.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,495.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,691.94. The transfer operating threshold is the transfer adjustment factor * $7,443.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.70. The transfer capital threshold is the transfer adjustment factor * $553.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3007.16","3007.16","3007.16","1 through 10","7100.73","8407.6278","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","29723.77","22292.83","MEDICARE [2001]","HB NWH MEDICARE","7245.64","","Case rate ($7,245.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,443.24, add-ons for qualifying new technology services are included. If operating cost exceeds $52,585.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,495.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,691.94. The transfer operating threshold is the transfer adjustment factor * $7,443.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.70. The transfer capital threshold is the transfer adjustment factor * $553.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8129.05","8114.46","8129.05","1 through 10","7100.73","8407.6278","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","31998.76","23999.07","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7576.34","","Case rate ($7,355.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,556.27, add-ons for qualifying new technology services are included. If operating cost exceeds $52,698.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,504.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,793.56. The transfer operating threshold is the transfer adjustment factor * $7,556.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.11. The transfer capital threshold is the transfer adjustment factor * $562.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7710.20","7710.20","7710.20","1 through 10","7208.56","8714.99","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","31998.76","23999.07","MEDICARE [2001]","HB NWH MEDICARE","8087.74","","Case rate ($8,087.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,556.27, add-ons for qualifying new technology services are included. If operating cost exceeds $52,698.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,504.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,525.63. The transfer operating threshold is the transfer adjustment factor * $7,556.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.11. The transfer capital threshold is the transfer adjustment factor * $562.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8219.44","104.56","8234.23","11","7208.56","8714.99","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","31998.76","23999.07","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7208.56","","Case rate ($7,355.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,556.27, add-ons for qualifying new technology services are included. If operating cost exceeds $52,698.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,504.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,793.56. The transfer operating threshold is the transfer adjustment factor * $7,556.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.11. The transfer capital threshold is the transfer adjustment factor * $562.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7373.45","7373.45","7373.45","1 through 10","7208.56","8714.99","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11456.42","","Case rate ($11,122.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,272.76. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11681.66","11678.12","11725.35","15","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12229.73","","Case rate ($12,229.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,379.75. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11255.28","11251.89","12276.01","1 through 10","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","FALLON HEALTH [1008]","HB NWH MEDICARE","12229.73","","Case rate ($12,229.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,379.75. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8570.54","8570.54","8570.54","1 through 10","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","HUMANA [1012]","HB NWH MEDICARE","12229.73","","Case rate ($12,229.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,379.75. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11166.36","11166.36","11175.42","1 through 10","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","MEDICARE [2001]","HB NWH MEDICARE","12229.73","","Case rate ($12,229.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,379.75. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12453.23","9596.25","12475.62","329","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10900.29","","Case rate ($11,122.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,272.76. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11128.01","53.15","11157.01","55","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","10900.29","","Case rate ($11,122.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,272.76. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12818.62","12818.62","12818.78","1 through 10","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","34407.12","25805.34","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","10900.29","","Case rate ($11,122.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,426.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,791.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,272.76. The transfer operating threshold is the transfer adjustment factor * $11,426.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.99. The transfer capital threshold is the transfer adjustment factor * $849.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11127.05","11121.86","11161.52","25","10900.29","13178.21","other","Inpatient DRG"
"Heart Failure And Shock Without Cc/McC","293","MS-DRG","","","","","","","","inpatient","","","14221.90","10666.42","MEDICARE [2001]","HB NWH MEDICARE","5391.83","","Case rate ($5,391.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,037.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,179.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,316.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,017.09. The transfer operating threshold is the transfer adjustment factor * $5,037.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.74. The transfer capital threshold is the transfer adjustment factor * $374.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5246.29","5246.29","5246.29","1 through 10","4805.7","5426.0943","other","Inpatient DRG"
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60003.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","34110.17","","Standard inlier is a Case rate ($34,110.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,842.07) for the length of stay and the standard reimbursement.","19368.28","19368.28","19368.28","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60003.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36641.13","","Standard inlier is a Case rate ($36,641.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,201.05) for the length of stay and the standard reimbursement.","36641.12","36641.12","36641.12","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60003.34","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","12070.37","","Fee schedule rate ($12,070.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17575.32","17575.32","17575.32","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60003.34","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","15459.64","","Case rate ($16,655.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,085.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19850.15","19850.15","19850.15","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22502.32","","Standard inlier is a Case rate ($22,502.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,194.29) for the length of stay and the standard reimbursement.","21479.77","21479.77","22502.31","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24171.98","","Standard inlier is a Case rate ($24,171.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,431.11) for the length of stay and the standard reimbursement.","23073.25","23073.25","24171.97","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11561.0472","","Fee schedule rate ($26,913.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11561.0472","26913.24","26913.24","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","29604.29","","Fee schedule rate ($29,604.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68476.86","68476.86","68476.86","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","MASSHEALTH [3001]","HB NWH MEDICAID","9587.88","","Case rate ($10,329.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,759.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,847.84 and the sum of the standard inlier and any outlier amount.","3860.16","1502.82","10355.99","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","9587.88","","Case rate ($10,329.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,759.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,847.84 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","27228.78","","Fee schedule rate ($27,228.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27228.78","27228.78","27228.78","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","44007.27","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9587.88","","Case rate ($10,329.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,759.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,847.84 and the sum of the standard inlier and any outlier amount.","10355.99","10355.99","86003.99","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MINOR","194","DRG","","","","","","","","inpatient","","","30103.16","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","13314.47","","Standard inlier is a Case rate ($13,314.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,364, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,889.93) for the length of stay and the standard reimbursement.","18374.12","18374.12","18374.12","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MINOR","194","DRG","","","","","","","","inpatient","","","30103.16","","MASSHEALTH [3001]","HB NWH MEDICAID","4775.09","","Case rate ($5,144.41). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,574.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $920.29 and the sum of the standard inlier and any outlier amount.","5157.63","5157.63","5157.63","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16268.15","","Standard inlier is a Case rate ($16,268.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,309.33) for the length of stay and the standard reimbursement.","1797.02","1797.02","16268.15","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17475.24","","Standard inlier is a Case rate ($17,475.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,480.54) for the length of stay and the standard reimbursement.","17475.24","16680.91","17475.24","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11561.0472","","Fee schedule rate ($15,856.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11561.0472","15856.38","15856.38","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","MASSHEALTH [3001]","HB NWH MEDICAID","6856.48","","Case rate ($7,386.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,816.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7405.77","7405.77","7405.77","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19540.80","","Fee schedule rate ($19,540.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19540.80","19540.80","19540.80","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","6856.48","","Case rate ($7,386.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,816.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7405.77","7405.77","7405.77","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","23622.32","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6856.48","","Case rate ($7,386.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,816.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7405.77","7405.77","7405.77","1 through 10","4775.09","101961.98","case rate",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","104.31","1 through 10","22.65","143.56","percent of total billed charges",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","136.85","136.84","136.85","1 through 10","22.65","143.56","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","115.00","86.25","AETNA [1001]","HB CH AETNA HMO / PPO","67.05","58.3","","63.50","63.50","63.50","1 through 10","12.75","109.25","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","115.00","86.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.20","59.3","","65.63","65.63","65.63","1 through 10","10.07","90.22","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.22","78.45","","86.11","40.60","86.11","1 through 10","10.07","90.22","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30001442","CDM","86682","CPT","0302","RC","","","","both","","","115.00","86.25","AETNA [1001]","HB CH AETNA HMO / PPO","67.05","58.3","","63.50","63.50","63.50","1 through 10","12.75","109.25","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30001442","CDM","86682","CPT","0302","RC","","","","outpatient","","","115.00","86.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.20","59.3","","65.63","65.63","65.63","1 through 10","10.07","90.22","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30001442","CDM","86682","CPT","0302","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.22","78.45","","86.11","40.60","86.11","1 through 10","10.07","90.22","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","111","12.61","100.7","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","106.00","79.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","77.38","73","","58.40","58.40","58.40","1 through 10","12.61","100.7","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.12","44.45","","79.19","79.19","79.19","1 through 10","12.61","100.7","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","106.00","79.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.12","44.45","","46.93","46.93","46.93","1 through 10","12.61","100.7","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","89","13.27","83.16","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","46.93","79.19","94","13.27","83.16","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","both","","","69.00","51.75","AETNA [1001]","HB CH AETNA HMO / PPO","40.23","58.3","","37.99","37.99","37.99","1 through 10","7.58","65.55","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","69.00","51.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","40.92","59.3","","39.26","39.26","39.26","1 through 10","5.98","54.13","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","69.00","51.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","54.13","78.45","","51.51","51.51","51.51","1 through 10","5.98","54.13","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0300","RC","","","","inpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.07","70.6","","83.80","49.66","83.80","1 through 10","62.72","79.07","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","61.80","1523","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","81.76","73","","79.57","79.57","79.57","1 through 10","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","61.80","1 through 10","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","81.76","73","","61.80","19.44","90.10","12","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","TRICARE [160005]","HB NWH TRICARE","106.40","95","","11.70","11.12","11.70","27","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","83.80","49.66","83.80","52","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","49.66","49.66","83.80","1 through 10","9.52","106.4","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","1510","10.01","87.86","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","62.35","63.87","1 through 10","10.01","87.86","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","10.01","87.86","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","49.66","83.80","1273","10.01","87.86","percent of total billed charges",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6177.29","6177.29","6177.29","1 through 10","2101.12","4842.11","other","Multiple Surgery"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MEDICARE [2001]","HB NWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3064.49","3256.75","13","2101.12","4842.11","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","2101.12","4842.11","per diem",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1702.00","1702.00","1702.00","1 through 10","2101.12","4842.11","per diem",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2101.12","4842.11","per diem",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3191.61","3191.61","3191.61","1 through 10","2101.12","4842.11","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3855.09","3775.00","3855.09","1 through 10","2101.12","7178","other","ASC "
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3780.34","3780.34","3860.43","1 through 10","2101.12","7178","other","ASC "
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","24688.15","14812.89","24688.15","1 through 10","2101.12","7178","other","Multiple Surgery"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5189.77","5189.77","5189.77","1 through 10","2101.12","7178","other","Multiple Surgery"
"Hemorrhoidectomy Singl Column/Group","PX-75000218","CDM","46255","CPT","0750","RC","","","","both","","","6419.00","4814.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2753.75","4685.87","per diem",""
"Hep Screen High Risk, Other","PX-30002827","CDM","G0472","HCPCS","0301","RC","","","","both","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.78","44.45","","69.96","69.96","69.96","1 through 10","41.78","180.3","percent of total billed charges",""
"Hep Screen High Risk, Other","PX-30002827","CDM","G0472","HCPCS","0301","RC","","","","outpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.74","59.3","","53.33","53.33","53.33","1 through 10","11.99","114.48","percent of total billed charges",""
"Hep Screen High Risk, Other","PX-30002827","CDM","G0472","HCPCS","0301","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","69.96","110.31","13","11.99","114.48","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","1 through 10","12.83","141.55","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","84.97","84.97","84.97","1 through 10","13.5","116.89","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","111.48","66.06","111.48","1 through 10","13.5","116.89","percent of total billed charges",""
"Heparin Neutralization","PX-30001106","CDM","85525","CPT","0305","RC","","","","both","","","140.00","105.00","AETNA [1001]","HB CH AETNA HMO / PPO","81.62","58.3","","77.11","77.11","77.11","1 through 10","11.6","133","percent of total billed charges",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","24651.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24098.24","","Standard inlier is a Case rate ($24,098.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,662, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,420.64) for the length of stay and the standard reimbursement.","24098.24","24098.24","24098.24","1 through 10","2050","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","24651.91","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","4476.00","","Per diem ($4,476). If length of stay < 7, first 1 days paid at a per diem of $8,952 instead.","31330.42","31330.42","31330.42","1 through 10","2050","124271.6","per diem","Estimated amount calculated based on 2 day length of stay."
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","24651.91","","MASSHEALTH [3001]","HB NWH MEDICAID","11051.25","","Case rate ($11,905.98). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,335.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,935.93 and the sum of the standard inlier and any outlier amount.","11936.60","11936.60","11936.60","1 through 10","2050","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","24651.91","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5140.00","","Per diem ($5,140). If length of stay < 4.61, first 1 days paid at a per diem of $10,280 instead.","15418.65","15418.65","15418.65","1 through 10","2050","124271.6","per diem","Estimated amount calculated based on 2 day length of stay."
"Hepatic Coma And Other Major Acute Liver Disorders,MINOR","279","DRG","","","","","","","","inpatient","","","11374.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12932.16","","Fee schedule rate ($12,932.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12932.16","12932.16","12932.16","1 through 10","2050","124271.6","case rate",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0300","RC","","","","inpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.56","56","","72.08","68.01","72.08","1 through 10","70.56","88.96","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0300","RC","","","","inpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.96","70.6","","94.56","56.04","94.56","1 through 10","70.56","88.96","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","69.74","69.74","69.74","518","8.01","119.7","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","TRICARE [160005]","HB NWH TRICARE","119.70","95","","9.84","7.38","9.84","1 through 10","8.01","119.7","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","90.24","56.04","94.56","16","8.01","119.7","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","56.04","56.04","56.04","1 through 10","8.01","119.7","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","72.08","72.08","118.94","589","8.43","98.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","123.00","94.56","123.00","1 through 10","8.43","98.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","56.04","94.56","383","8.43","98.85","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","132.00","99.00","AETNA [1001]","HB CH AETNA HMO / PPO","76.96","58.3","","72.58","72.58","145.16","11","11.03","125.4","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","132.00","99.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.28","59.3","","75.01","75.01","75.01","1 through 10","11.62","103.55","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","103.55","78.45","","98.41","58.32","98.41","1 through 10","11.62","103.55","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","146.28","15","12.14","126.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","133.00","99.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","97.09","73","","94.17","94.17","94.17","1 through 10","12.14","126.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","133.00","99.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.87","59.3","","75.59","75.59","75.59","13","11.99","104.34","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","104.34","78.45","","99.18","99.18","99.18","11","11.99","104.34","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","111.14","15","11.53","95.95","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.89","44.45","","72.04","72.04","72.04","1 through 10","11.53","95.95","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","13","12.15","79.23","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","44.65","75.34","1 through 10","12.15","79.23","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","141","11.81","132.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","98.55","98.55","98.55","1 through 10","11.81","132.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","76.55","76.55","76.55","1 through 10","11.81","132.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","TRICARE [160005]","HB NWH TRICARE","132.05","95","","13.79","13.79","14.52","1 through 10","11.81","132.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","61.51","103.79","1 through 10","11.81","132.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","79.11","117","12.43","109.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","103.79","61.51","103.79","121","12.43","109.05","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","AETNA [1001]","HB CH AETNA HMO / PPO","71.13","58.3","","67.47","67.47","67.47","166","10.53","115.9","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","89.06","73","","86.87","86.87","86.87","1 through 10","10.53","115.9","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.06","73","","119.00","67.47","119.00","1 through 10","10.53","115.9","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","TRICARE [160005]","HB NWH TRICARE","115.90","95","","12.94","12.29","12.94","1 through 10","10.53","115.9","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.23","44.45","","91.49","54.22","91.49","11","10.53","115.9","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","69.73","69.73","69.73","159","10.79","95.71","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","91.49","54.22","91.49","155","10.79","95.71","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","11.34","91.2","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","11","11.93","75.31","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","37.07","71.50","1 through 10","11.93","75.31","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","454","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","75.92","73","","73.73","73.73","73.73","1 through 10","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.92","73","","57.27","13.98","57.27","1 through 10","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","TRICARE [160005]","HB NWH TRICARE","98.80","95","","16.34","16.34","17.20","1 through 10","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.23","44.45","","77.65","46.02","77.65","18","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.23","44.45","","77.65","46.02","77.65","1 through 10","13.98","98.8","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","59.19","59.19","59.19","371","11.99","81.59","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","46.02","77.65","352","11.99","81.59","percent of total billed charges",""
"Hepatitis Delta Agent Antibody","PX-30000943","CDM","86692","CPT","0302","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","16.82","131.1","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igg","PX-30003658","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","78.85","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igg","PX-30003658","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","9.6","65.11","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igg","PX-30003658","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","36.90","36.90","36.90","1 through 10","9.6","65.11","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igm","PX-30003657","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","78.85","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igm","PX-30003657","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","9.6","65.11","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igm","PX-30003657","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","36.90","36.90","36.90","1 through 10","9.6","65.11","percent of total billed charges",""
"Hepb Vaccine Adult 3 Dose Schedule for Im Use","PX-63600327","CDM","90746","CPT","0636","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","47.06","47.06","47.06","1 through 10","43.99","235.77","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","50896.69","38172.52","MEDICARE [2001]","HB NWH MEDICARE","16026.88","","Case rate ($16,026.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,973.70, add-ons for qualifying new technology services are included. If operating cost exceeds $60,115.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,055.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,912.99. The transfer operating threshold is the transfer adjustment factor * $14,973.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,113.90. The transfer capital threshold is the transfer adjustment factor * $1,113.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16264.78","16264.78","16264.78","1 through 10","14284.67","17269.84","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With McC","353","MS-DRG","","","","","","","","inpatient","","","40395.83","30296.87","MEDICARE [2001]","HB NWH MEDICARE","27645.05","","Case rate ($27,645.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,828.40, add-ons for qualifying new technology services are included. If operating cost exceeds $70,970.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,863.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $25,723.66. The transfer operating threshold is the transfer adjustment factor * $25,828.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,921.38. The transfer capital threshold is the transfer adjustment factor * $1,921.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28043.38","28043.38","28043.38","1 through 10","24639.87","29004.437","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","40755.22","30566.41","MEDICARE [2001]","HB NWH MEDICARE","11652.98","","Case rate ($11,652.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,970.77, add-ons for qualifying new technology services are included. If operating cost exceeds $57,113.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,832.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,762.47. The transfer operating threshold is the transfer adjustment factor * $11,970.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $890.51. The transfer capital threshold is the transfer adjustment factor * $890.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12747.16","12747.16","12747.16","1 through 10","11419.92","13806.43","other","Inpatient Replacement Plans DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","40755.22","30566.41","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11419.92","","Case rate ($11,652.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,970.77, add-ons for qualifying new technology services are included. If operating cost exceeds $57,113.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,832.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,762.47. The transfer operating threshold is the transfer adjustment factor * $11,970.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $890.51. The transfer capital threshold is the transfer adjustment factor * $890.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11375.14","11375.14","11375.14","1 through 10","11419.92","13806.43","other","Inpatient DRG"
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MAJOR","227","DRG","","","","","","","","inpatient","","","46777.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","53795.10","","Standard inlier is a Case rate ($53,795.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $63,023, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,635.99) for the length of stay and the standard reimbursement.","51349.86","51349.86","51349.86","1 through 10","9795.79","80235.97","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","45117.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30426.30","","Standard inlier is a Case rate ($30,426.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,318.89) for the length of stay and the standard reimbursement.","30426.30","30426.30","30426.30","1 through 10","9795.79","80235.97","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","45117.90","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13441.91","","Fee schedule rate ($13,441.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13441.91","13441.91","13441.91","1 through 10","9795.79","80235.97","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","45117.90","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28650.78","","Fee schedule rate ($28,650.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28650.78","28650.78","28650.78","1 through 10","9795.79","80235.97","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","40755.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38063.16","","Standard inlier is a Case rate ($38,063.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,000, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,402.91) for the length of stay and the standard reimbursement.","38063.16","38063.16","38063.16","1 through 10","9795.79","80235.97","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","40755.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","19704.1986","","Fee schedule rate ($26,082.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19704.1986","25077.68","25077.68","1 through 10","9795.79","80235.97","case rate",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","both","","","109.00","81.75","AETNA [1001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","11","12.93","103.55","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","both","","","109.00","81.75","TRICARE [160005]","HB NWH TRICARE","103.55","95","","15.10","15.10","15.10","1 through 10","12.93","103.55","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","109.00","81.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","1 through 10","13.6","85.51","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","48.29","48.29","81.49","1 through 10","13.6","85.51","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","87.89","87.89","87.89","11","18.96","151.05","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","both","","","159.00","119.25","TRICARE [160005]","HB NWH TRICARE","151.05","95","","22.15","22.15","22.15","1 through 10","18.96","151.05","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","159.00","119.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","1 through 10","19.95","124.74","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","124.74","78.45","","70.62","70.62","119.16","1 through 10","19.95","124.74","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","1 through 10","5.08","43.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","46.00","34.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","33.58","73","","25.52","25.52","25.52","1 through 10","5.08","43.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","39.01","22","5.34","36.09","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","46.00","34.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","34.60","34.60","1 through 10","5.34","36.09","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","20.50","34.60","1 through 10","5.34","36.09","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","AETNA [1001]","HB CH AETNA HMO / PPO","127.00","58.3","","123.52","123.52","123.52","1 through 10","115.46","924.27","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","125.69","57.7","","480.56","131.36","480.56","1 through 10","96.83","613.61","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","131.79","60.5","","137.89","132.66","137.89","1 through 10","96.83","613.61","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.90","78.45","","167.48","167.48","167.48","1 through 10","96.83","613.61","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","AETNA [1001]","HB CH AETNA HMO / PPO","2272.61","58.3","","1530.90","1160.93","1884.08","89","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2066.01","53","","5253.92","5253.92","5253.92","1 through 10","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2260.92","58","","12181.47","12181.47","12181.47","1 through 10","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2436.33","62.5","","1350.68","1350.68","1350.68","1 through 10","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.72","44.45","","1910.74","891.94","1910.74","1 through 10","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","both","","","3898.13","2923.60","WELLPOINT [1015]","HB CH WELLPOINT","3037.03","77.91","","1829.79","1561.50","2617.12","88","1732.72","3037.03","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3898.13","2923.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","2311.59","59.3","","1359.46","1201.30","1689.00","61","1949.07","3058.08","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3898.13","2923.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2311.59","59.3","","1718.92","1718.92","1718.92","1 through 10","1949.07","3058.08","percent of total billed charges",""
"HINGE ARTICULAR 12MM IMPLANT KNEE SIZE D TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10014983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3898.13","2923.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3058.08","78.45","","1910.74","1019.06","2344.84","74","1949.07","3058.08","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","AETNA [1001]","HB CH AETNA HMO / PPO","1394.83","58.3","","1530.90","1160.93","1884.08","89","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1268.03","53","","5253.92","5253.92","5253.92","1 through 10","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1387.65","58","","12181.47","12181.47","12181.47","1 through 10","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1495.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1063.47","44.45","","1910.74","891.94","1910.74","1 through 10","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.50","1794.37","WELLPOINT [1015]","HB CH WELLPOINT","1864.00","77.91","","1829.79","1561.50","2617.12","88","1063.47","1864","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.50","1794.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1418.75","59.3","","1359.46","1201.30","1689.00","61","1196.25","1876.92","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.50","1794.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1418.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1196.25","1876.92","percent of total billed charges",""
"HINGE BUMPER NEUTRAL TRIATHLON","SUP-ITM-10322168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.50","1794.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1876.92","78.45","","1910.74","1019.06","2344.84","74","1196.25","1876.92","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","AETNA [1001]","HB CH AETNA HMO / PPO","3245.62","58.3","","1530.90","1160.93","1884.08","89","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2950.56","53","","5253.92","5253.92","5253.92","1 through 10","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3228.92","58","","12181.47","12181.47","12181.47","1 through 10","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3479.44","62.5","","1350.68","1350.68","1350.68","1 through 10","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2474.58","44.45","","1910.74","891.94","1910.74","1 through 10","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","5567.10","4175.32","WELLPOINT [1015]","HB CH WELLPOINT","4337.33","77.91","","1829.79","1561.50","2617.12","88","2474.58","4337.33","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5567.10","4175.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","3301.29","59.3","","1359.46","1201.30","1689.00","61","2783.55","4367.39","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5567.10","4175.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3301.29","59.3","","1718.92","1718.92","1718.92","1 through 10","2783.55","4367.39","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5567.10","4175.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4367.39","78.45","","1910.74","1019.06","2344.84","74","2783.55","4367.39","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","AETNA [1001]","HB CH AETNA HMO / PPO","4984.65","58.3","","1530.90","1160.93","1884.08","89","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4531.50","53","","5253.92","5253.92","5253.92","1 through 10","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4959.00","58","","12181.47","12181.47","12181.47","1 through 10","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3800.48","44.45","","1910.74","891.94","1910.74","1 through 10","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","WELLPOINT [1015]","HB CH WELLPOINT","6661.31","77.91","","1829.79","1561.50","2617.12","88","3800.48","6661.31","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5070.15","59.3","","1359.46","1201.30","1689.00","61","4275","6707.48","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5070.15","59.3","","1718.92","1718.92","1718.92","1 through 10","4275","6707.48","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR RIGHT","SUP-ITM-10035438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6707.48","78.45","","1910.74","1019.06","2344.84","74","4275","6707.48","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","AETNA [1001]","HB CH AETNA HMO / PPO","1603.83","58.3","","1530.90","1160.93","1884.08","89","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1458.03","53","","5253.92","5253.92","5253.92","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1595.58","58","","12181.47","12181.47","12181.47","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1719.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1222.82","44.45","","1910.74","891.94","1910.74","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","WELLPOINT [1015]","HB CH WELLPOINT","2143.30","77.91","","1829.79","1561.50","2617.12","88","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1631.34","59.3","","1359.46","1201.30","1689.00","61","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1631.34","59.3","","1718.92","1718.92","1718.92","1 through 10","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON 16.6X40.2MM SM SIZE 1S PROSTHESIS JOINT TOE FLEXIBLE GROMMETT STEM","SUP-ITM-10057355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2158.16","78.45","","1910.74","1019.06","2344.84","74","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","AETNA [1001]","HB CH AETNA HMO / PPO","1603.83","58.3","","1530.90","1160.93","1884.08","89","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1458.03","53","","5253.92","5253.92","5253.92","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1595.58","58","","12181.47","12181.47","12181.47","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1719.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1222.82","44.45","","1910.74","891.94","1910.74","1 through 10","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","WELLPOINT [1015]","HB CH WELLPOINT","2143.30","77.91","","1829.79","1561.50","2617.12","88","1222.82","2143.3","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1631.34","59.3","","1359.46","1201.30","1689.00","61","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1631.34","59.3","","1718.92","1718.92","1718.92","1 through 10","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON SIZE 4 PROSTHESIS JOINT TOE FLEXIBLE GROMMET S","SUP-ITM-10027679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2158.16","78.45","","1910.74","1019.06","2344.84","74","1375.5","2158.16","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","AETNA [1001]","HB CH AETNA HMO / PPO","7817.16","58.3","","1530.90","1160.93","1884.08","89","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7106.51","53","","5253.92","5253.92","5253.92","1 through 10","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7776.93","58","","12181.47","12181.47","12181.47","1 through 10","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8380.31","62.5","","1350.68","1350.68","1350.68","1 through 10","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5960.08","44.45","","1910.74","891.94","1910.74","1 through 10","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","both","","","13408.50","10056.37","WELLPOINT [1015]","HB CH WELLPOINT","10446.56","77.91","","1829.79","1561.50","2617.12","88","5960.08","10446.56","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13408.50","10056.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","7951.24","59.3","","1359.46","1201.30","1689.00","61","6704.25","10518.97","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13408.50","10056.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7951.24","59.3","","1718.92","1718.92","1718.92","1 through 10","6704.25","10518.97","percent of total billed charges",""
"HINGE ZIMALOY 54X64MM COMPONENT KNEE NEXGEN ROTATING LT SIZE B","SUP-ITM-10075260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13408.50","10056.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10518.97","78.45","","1910.74","1019.06","2344.84","74","6704.25","10518.97","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","AETNA [1001]","HB CH AETNA HMO / PPO","923.47","58.3","","1530.90","1160.93","1884.08","89","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","839.52","53","","5253.92","5253.92","5253.92","1 through 10","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","918.72","58","","12181.47","12181.47","12181.47","1 through 10","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","990.00","62.5","","1350.68","1350.68","1350.68","1 through 10","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.09","44.45","","1910.74","891.94","1910.74","1 through 10","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","WELLPOINT [1015]","HB CH WELLPOINT","1234.09","77.91","","1829.79","1561.50","2617.12","88","704.09","1234.09","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","939.31","59.3","","1359.46","1201.30","1689.00","61","792","1242.65","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","939.31","59.3","","1718.92","1718.92","1718.92","1 through 10","792","1242.65","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1242.65","78.45","","1910.74","1019.06","2344.84","74","792","1242.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1530.90","1160.93","1884.08","89","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","5253.92","5253.92","5253.92","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","12181.47","12181.47","12181.47","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","1350.68","1350.68","1350.68","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1910.74","891.94","1910.74","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","1829.79","1561.50","2617.12","88","560.07","981.67","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1359.46","1201.30","1689.00","61","630","988.47","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","1718.92","1718.92","1718.92","1 through 10","630","988.47","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1910.74","1019.06","2344.84","74","630","988.47","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1530.90","1160.93","1884.08","89","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","5253.92","5253.92","5253.92","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","12181.47","12181.47","12181.47","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","1350.68","1350.68","1350.68","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1910.74","891.94","1910.74","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","1829.79","1561.50","2617.12","88","560.07","981.67","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1359.46","1201.30","1689.00","61","630","988.47","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","1718.92","1718.92","1718.92","1 through 10","630","988.47","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1910.74","1019.06","2344.84","74","630","988.47","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1530.90","1160.93","1884.08","89","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","5253.92","5253.92","5253.92","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.00","58","","12181.47","12181.47","12181.47","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.50","62.5","","1350.68","1350.68","1350.68","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","1910.74","891.94","1910.74","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","1829.79","1561.50","2617.12","88","400.05","701.19","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1359.46","1201.30","1689.00","61","450","706.05","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.70","59.3","","1718.92","1718.92","1718.92","1 through 10","450","706.05","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1910.74","1019.06","2344.84","74","450","706.05","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","AETNA [1001]","HB CH AETNA HMO / PPO","526.45","58.3","","1530.90","1160.93","1884.08","89","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.59","53","","5253.92","5253.92","5253.92","1 through 10","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","523.74","58","","12181.47","12181.47","12181.47","1 through 10","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","564.38","62.5","","1350.68","1350.68","1350.68","1 through 10","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.38","44.45","","1910.74","891.94","1910.74","1 through 10","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","WELLPOINT [1015]","HB CH WELLPOINT","703.53","77.91","","1829.79","1561.50","2617.12","88","401.38","703.53","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.48","59.3","","1359.46","1201.30","1689.00","61","451.5","708.4","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","535.48","59.3","","1718.92","1718.92","1718.92","1 through 10","451.5","708.4","percent of total billed charges",""
"HIP 36MM 5 IMPLANT PLUS HD SKIRTLESS PCA VITALLIUM COBALT 05","SUP-ITM-10024944","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","708.40","78.45","","1910.74","1019.06","2344.84","74","451.5","708.4","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","AETNA [1001]","HB CH AETNA HMO / PPO","2144.97","58.3","","1530.90","1160.93","1884.08","89","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1949.98","53","","5253.92","5253.92","5253.92","1 through 10","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2133.94","58","","12181.47","12181.47","12181.47","1 through 10","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2299.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1635.40","44.45","","1910.74","891.94","1910.74","1 through 10","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","both","","","3679.20","2759.40","WELLPOINT [1015]","HB CH WELLPOINT","2866.46","77.91","","1829.79","1561.50","2617.12","88","1635.4","2866.46","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3679.20","2759.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","2181.77","59.3","","1359.46","1201.30","1689.00","61","1839.6","2886.33","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3679.20","2759.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2181.77","59.3","","1718.92","1718.92","1718.92","1 through 10","1839.6","2886.33","percent of total billed charges",""
"HIP 3X36MM MODULAR FREEDOM LINEAR CONSTRAINED PLUS","SUP-ITM-10122727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3679.20","2759.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2886.33","78.45","","1910.74","1019.06","2344.84","74","1839.6","2886.33","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1530.90","1160.93","1884.08","89","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","5253.92","5253.92","5253.92","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.00","58","","12181.47","12181.47","12181.47","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.50","62.5","","1350.68","1350.68","1350.68","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","1910.74","891.94","1910.74","1 through 10","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","1829.79","1561.50","2617.12","88","400.05","701.19","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1359.46","1201.30","1689.00","61","450","706.05","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.70","59.3","","1718.92","1718.92","1718.92","1 through 10","450","706.05","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1910.74","1019.06","2344.84","74","450","706.05","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1530.90","1160.93","1884.08","89","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","5253.92","5253.92","5253.92","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","12181.47","12181.47","12181.47","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","1350.68","1350.68","1350.68","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1910.74","891.94","1910.74","1 through 10","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","1829.79","1561.50","2617.12","88","560.07","981.67","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1359.46","1201.30","1689.00","61","630","988.47","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","1718.92","1718.92","1718.92","1 through 10","630","988.47","percent of total billed charges",""
"HIP 40MM 3.5 HD BIOLOX DELTA CERAMIC PLUS IMPLANT 04","SUP-ITM-10061790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1910.74","1019.06","2344.84","74","630","988.47","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1530.90","1160.93","1884.08","89","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","5253.92","5253.92","5253.92","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","12181.47","12181.47","12181.47","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1910.74","891.94","1910.74","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1829.79","1561.50","2617.12","88","533.4","934.92","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1359.46","1201.30","1689.00","61","600","941.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","1718.92","1718.92","1718.92","1 through 10","600","941.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1910.74","1019.06","2344.84","74","600","941.4","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","1530.90","1160.93","1884.08","89","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","5253.92","5253.92","5253.92","1 through 10","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","12181.47","12181.47","12181.47","1 through 10","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","1350.68","1350.68","1350.68","1 through 10","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1910.74","891.94","1910.74","1 through 10","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","1829.79","1561.50","2617.12","88","366.71","642.76","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","1359.46","1201.30","1689.00","61","412.5","647.21","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","1718.92","1718.92","1718.92","1 through 10","412.5","647.21","percent of total billed charges",""
"HIP 45MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10002224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1910.74","1019.06","2344.84","74","412.5","647.21","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","AETNA [1001]","HB CH AETNA HMO / PPO","2775.08","58.3","","1530.90","1160.93","1884.08","89","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2522.80","53","","5253.92","5253.92","5253.92","1 through 10","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2760.80","58","","12181.47","12181.47","12181.47","1 through 10","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2975.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2115.82","44.45","","1910.74","891.94","1910.74","1 through 10","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","WELLPOINT [1015]","HB CH WELLPOINT","3708.52","77.91","","1829.79","1561.50","2617.12","88","2115.82","3708.52","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4760.00","3570.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2822.68","59.3","","1359.46","1201.30","1689.00","61","2380","3734.22","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4760.00","3570.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2822.68","59.3","","1718.92","1718.92","1718.92","1 through 10","2380","3734.22","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4760.00","3570.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3734.22","78.45","","1910.74","1019.06","2344.84","74","2380","3734.22","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"HIP 56MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10118279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"Hip And Femur Fracture Repair,MAJOR","308","DRG","","","","","","","","inpatient","","","49297.04","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","17714.67","","Case rate ($19,084.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $61,514.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19133.84","19133.84","19133.84","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","46715.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","33664.00","","Standard inlier is a Case rate ($33,664.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,183, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,778.74) for the length of stay and the standard reimbursement.","33663.99","33663.99","33663.99","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","46715.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36161.85","","Standard inlier is a Case rate ($36,161.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,183, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,133.02) for the length of stay and the standard reimbursement.","34518.12","34518.12","34518.12","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","46715.50","","MASSHEALTH [3001]","HB NWH MEDICAID","13950.57","","Case rate ($15,029.54). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,459.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12394.37","12394.37","12394.37","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Fracture Repair,MODERATE","308","DRG","","","","","","","","inpatient","","","52506.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","42655.81","","Standard inlier is a Case rate ($42,655.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $52,384, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,054.81) for the length of stay and the standard reimbursement.","42655.81","42655.81","42655.81","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Fracture Repair,MODERATE","308","DRG","","","","","","","","inpatient","","","52506.38","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","17790.72","","Fee schedule rate ($17,790.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17790.72","17790.72","17790.72","1 through 10","13950.57","87207.12","case rate",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","18690.99","","Case rate ($18,146.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,759.85. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18615.74","18615.74","18615.74","1 through 10","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","19952.63","","Case rate ($19,952.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,565.89. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17892.83","17892.83","17892.83","1 through 10","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","HUMANA [1012]","HB NWH MEDICARE","19952.63","","Case rate ($19,952.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,565.89. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12247.06","12247.06","12247.06","1 through 10","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","MEDICARE [2001]","HB NWH MEDICARE","19952.63","","Case rate ($19,952.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,565.89. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19803.20","18902.15","19838.80","44","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","17783.66","","Case rate ($18,146.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,759.85. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17697.66","17690.30","17706.30","1 through 10","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","57441.17","43080.88","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17783.66","","Case rate ($18,146.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,641.48, add-ons for qualifying new technology services are included. If operating cost exceeds $63,783.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,328.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,759.85. The transfer operating threshold is the transfer adjustment factor * $18,641.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.74. The transfer capital threshold is the transfer adjustment factor * $1,386.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17691.66","17691.66","17708.80","1 through 10","17783.66","21500.04","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","66814.26","50110.69","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","27743.17","","Case rate ($27,743.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,920.07, add-ons for qualifying new technology services are included. If operating cost exceeds $71,062.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,870.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,814.96. The transfer operating threshold is the transfer adjustment factor * $25,920.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.20. The transfer capital threshold is the transfer adjustment factor * $1,928.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25361.26","25361.26","25361.26","1 through 10","24727.32","29083.549","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","66814.26","50110.69","MEDICARE [2001]","HB NWH MEDICARE","27743.17","","Case rate ($27,743.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,920.07, add-ons for qualifying new technology services are included. If operating cost exceeds $71,062.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,870.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,814.96. The transfer operating threshold is the transfer adjustment factor * $25,920.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.20. The transfer capital threshold is the transfer adjustment factor * $1,928.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27401.36","22987.99","28119.88","25","24727.32","29083.549","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","66814.26","50110.69","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","24727.32","","Case rate ($25,231.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,920.07, add-ons for qualifying new technology services are included. If operating cost exceeds $71,062.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,870.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,303.75. The transfer operating threshold is the transfer adjustment factor * $25,920.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.20. The transfer capital threshold is the transfer adjustment factor * $1,928.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25074.87","25074.87","25074.87","1 through 10","24727.32","29083.549","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","66814.26","50110.69","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","24727.32","","Case rate ($25,231.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,920.07, add-ons for qualifying new technology services are included. If operating cost exceeds $71,062.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,870.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,303.75. The transfer operating threshold is the transfer adjustment factor * $25,920.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.20. The transfer capital threshold is the transfer adjustment factor * $1,928.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20493.51","20493.51","20493.51","1 through 10","24727.32","29083.549","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","52067.76","39050.82","MEDICARE [2001]","HB NWH MEDICARE","14130.86","","Case rate ($14,130.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,516.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,658.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,051.00. The transfer operating threshold is the transfer adjustment factor * $14,516.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.87. The transfer capital threshold is the transfer adjustment factor * $1,079.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15168.09","15140.88","15168.09","1 through 10","13848.24","15687.9096","other","Inpatient Replacement Plans DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","52067.76","39050.82","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","13848.24","","Case rate ($14,130.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,516.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,658.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,051.00. The transfer operating threshold is the transfer adjustment factor * $14,516.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.87. The transfer capital threshold is the transfer adjustment factor * $1,079.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15433.32","15433.32","15433.32","1 through 10","13848.24","15687.9096","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","52067.76","39050.82","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13848.24","","Case rate ($14,130.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,516.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,658.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,021.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,051.00. The transfer operating threshold is the transfer adjustment factor * $14,516.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.87. The transfer capital threshold is the transfer adjustment factor * $1,079.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13556.46","13556.46","13556.46","1 through 10","13848.24","15687.9096","other","Inpatient DRG"
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","464.71","67.87","1012.10","221","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","293.04","293.04","293.04","11","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","983.89","983.89","983.89","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","677.18","677.18","677.18","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","46.58","46.58","46.58","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","747.15","747.15","747.15","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1141.67","481.21","1141.67","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","76.54","76.54","76.54","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","273.64","94.28","1367.51","138","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","720.78","230.14","2010.94","427","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","344.45","344.45","344.45","1 through 10","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1120.13","1120.13","1120.13","1 through 10","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 10.5MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","456.17","105.33","1284.66","242","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1530.90","1160.93","1884.08","89","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","5253.92","5253.92","5253.92","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","12181.47","12181.47","12181.47","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","1350.68","1350.68","1350.68","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1910.74","891.94","1910.74","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","1829.79","1561.50","2617.12","88","66.68","116.87","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1359.46","1201.30","1689.00","61","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","1718.92","1718.92","1718.92","1 through 10","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1910.74","1019.06","2344.84","74","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","AETNA [1001]","HB CH AETNA HMO / PPO","91.82","58.3","","1530.90","1160.93","1884.08","89","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","83.48","53","","5253.92","5253.92","5253.92","1 through 10","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","91.35","58","","12181.47","12181.47","12181.47","1 through 10","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","98.44","62.5","","1350.68","1350.68","1350.68","1 through 10","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","1910.74","891.94","1910.74","1 through 10","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB CH WELLPOINT","122.71","77.91","","1829.79","1561.50","2617.12","88","70.01","122.71","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.40","59.3","","1359.46","1201.30","1689.00","61","78.75","123.56","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","93.40","59.3","","1718.92","1718.92","1718.92","1 through 10","78.75","123.56","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","1910.74","1019.06","2344.84","74","78.75","123.56","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1530.90","1160.93","1884.08","89","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","5253.92","5253.92","5253.92","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","12181.47","12181.47","12181.47","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1910.74","891.94","1910.74","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1829.79","1561.50","2617.12","88","533.4","934.92","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1359.46","1201.30","1689.00","61","600","941.4","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","1718.92","1718.92","1718.92","1 through 10","600","941.4","percent of total billed charges",""
"HIP COMPONENT 28MM PLUS 1.5 ARTICULEZE STD METAL 12/14 OFFSET","SUP-ITM-10004683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1910.74","1019.06","2344.84","74","600","941.4","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1530.90","1160.93","1884.08","89","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","5253.92","5253.92","5253.92","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","12181.47","12181.47","12181.47","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1910.74","891.94","1910.74","1 through 10","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1829.79","1561.50","2617.12","88","533.4","934.92","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1359.46","1201.30","1689.00","61","600","941.4","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","1718.92","1718.92","1718.92","1 through 10","600","941.4","percent of total billed charges",""
"HIP H 41MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10035828","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1910.74","1019.06","2344.84","74","600","941.4","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1530.90","1160.93","1884.08","89","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","5253.92","5253.92","5253.92","1 through 10","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","12181.47","12181.47","12181.47","1 through 10","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","1350.68","1350.68","1350.68","1 through 10","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1910.74","891.94","1910.74","1 through 10","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","1829.79","1561.50","2617.12","88","733.43","1285.52","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1359.46","1201.30","1689.00","61","825","1294.43","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","1718.92","1718.92","1718.92","1 through 10","825","1294.43","percent of total billed charges",""
"HIP HEAD 0MM UNIVERSAL SZ 40 FEMORAL BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10031082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1910.74","1019.06","2344.84","74","825","1294.43","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","AETNA [1001]","HB CH AETNA HMO / PPO","1780.48","58.3","","1530.90","1160.93","1884.08","89","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1618.62","53","","5253.92","5253.92","5253.92","1 through 10","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1771.32","58","","12181.47","12181.47","12181.47","1 through 10","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1908.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.50","44.45","","1910.74","891.94","1910.74","1 through 10","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","WELLPOINT [1015]","HB CH WELLPOINT","2379.37","77.91","","1829.79","1561.50","2617.12","88","1357.5","2379.37","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1359.46","1201.30","1689.00","61","1527","2395.86","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1718.92","1718.92","1718.92","1 through 10","1527","2395.86","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2395.86","78.45","","1910.74","1019.06","2344.84","74","1527","2395.86","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1530.90","1160.93","1884.08","89","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","5253.92","5253.92","5253.92","1 through 10","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","607.26","58","","12181.47","12181.47","12181.47","1 through 10","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","654.38","62.5","","1350.68","1350.68","1350.68","1 through 10","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","1910.74","891.94","1910.74","1 through 10","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","1829.79","1561.50","2617.12","88","465.39","815.72","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1359.46","1201.30","1689.00","61","523.5","821.37","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","620.87","59.3","","1718.92","1718.92","1718.92","1 through 10","523.5","821.37","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","1910.74","1019.06","2344.84","74","523.5","821.37","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"HIP IMPLANT SZ3 STEM STARDARD OFFSET SPARTAN","SUP-ITM-10319698","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","AETNA [1001]","HB CH AETNA HMO / PPO","1311.75","58.3","","1530.90","1160.93","1884.08","89","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1192.50","53","","5253.92","5253.92","5253.92","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1305.00","58","","12181.47","12181.47","12181.47","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1406.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.13","44.45","","1910.74","891.94","1910.74","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","WELLPOINT [1015]","HB CH WELLPOINT","1752.98","77.91","","1829.79","1561.50","2617.12","88","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1359.46","1201.30","1689.00","61","1125","1765.13","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1125","1765.13","percent of total billed charges",""
"HIP INSERT 22/40 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280242","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","1910.74","1019.06","2344.84","74","1125","1765.13","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","AETNA [1001]","HB CH AETNA HMO / PPO","1311.75","58.3","","1530.90","1160.93","1884.08","89","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1192.50","53","","5253.92","5253.92","5253.92","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1305.00","58","","12181.47","12181.47","12181.47","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1406.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.13","44.45","","1910.74","891.94","1910.74","1 through 10","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","WELLPOINT [1015]","HB CH WELLPOINT","1752.98","77.91","","1829.79","1561.50","2617.12","88","1000.13","1752.98","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1359.46","1201.30","1689.00","61","1125","1765.13","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1125","1765.13","percent of total billed charges",""
"HIP INSERT 28/50 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","1910.74","1019.06","2344.84","74","1125","1765.13","percent of total billed charges",""
"Hip Joint Replacement,MAJOR","301","DRG","","","","","","","","inpatient","","","73371.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","41100.7344","","Fee schedule rate ($54,209.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41100.7344","52120.68","52120.68","1 through 10","15606.47","89444.86","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","60021.93","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","41100.7344","","Fee schedule rate ($42,810.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41100.7344","42810.66","42810.66","1 through 10","15606.47","89444.86","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","60021.93","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","40903.88","","Fee schedule rate ($40,903.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40903.88","40903.88","40903.88","1 through 10","15606.47","89444.86","case rate",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","1530.90","1160.93","1884.08","89","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","5253.92","5253.92","5253.92","1 through 10","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.10","58","","12181.47","12181.47","12181.47","1 through 10","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","590.63","62.5","","1350.68","1350.68","1350.68","1 through 10","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","1910.74","891.94","1910.74","1 through 10","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","1829.79","1561.50","2617.12","88","420.05","736.25","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","1359.46","1201.30","1689.00","61","472.5","741.35","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.39","59.3","","1718.92","1718.92","1718.92","1 through 10","472.5","741.35","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","1910.74","1019.06","2344.84","74","472.5","741.35","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","AETNA [1001]","HB CH AETNA HMO / PPO","2516.71","58.3","","1530.90","1160.93","1884.08","89","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2287.92","53","","5253.92","5253.92","5253.92","1 through 10","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2503.76","58","","12181.47","12181.47","12181.47","1 through 10","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2698.02","62.5","","1350.68","1350.68","1350.68","1 through 10","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1918.83","44.45","","1910.74","891.94","1910.74","1 through 10","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","WELLPOINT [1015]","HB CH WELLPOINT","3363.24","77.91","","1829.79","1561.50","2617.12","88","1918.83","3363.24","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4316.83","3237.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2559.88","59.3","","1359.46","1201.30","1689.00","61","2158.42","3386.55","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4316.83","3237.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2559.88","59.3","","1718.92","1718.92","1718.92","1 through 10","2158.42","3386.55","percent of total billed charges",""
"HIP LINER 36MM D ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4316.83","3237.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3386.55","78.45","","1910.74","1019.06","2344.84","74","2158.42","3386.55","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","AETNA [1001]","HB CH AETNA HMO / PPO","2444.32","58.3","","1530.90","1160.93","1884.08","89","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2222.11","53","","5253.92","5253.92","5253.92","1 through 10","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2431.74","58","","12181.47","12181.47","12181.47","1 through 10","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2620.41","62.5","","1350.68","1350.68","1350.68","1 through 10","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1863.64","44.45","","1910.74","891.94","1910.74","1 through 10","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","WELLPOINT [1015]","HB CH WELLPOINT","3266.50","77.91","","1829.79","1561.50","2617.12","88","1863.64","3266.5","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4192.66","3144.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","2486.25","59.3","","1359.46","1201.30","1689.00","61","2096.33","3289.14","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4192.66","3144.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2486.25","59.3","","1718.92","1718.92","1718.92","1 through 10","2096.33","3289.14","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4192.66","3144.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3289.14","78.45","","1910.74","1019.06","2344.84","74","2096.33","3289.14","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","1530.90","1160.93","1884.08","89","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","5253.92","5253.92","5253.92","1 through 10","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1270.20","58","","12181.47","12181.47","12181.47","1 through 10","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1368.75","62.5","","1350.68","1350.68","1350.68","1 through 10","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","1910.74","891.94","1910.74","1 through 10","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","1829.79","1561.50","2617.12","88","973.46","1706.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1359.46","1201.30","1689.00","61","1095","1718.06","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1095","1718.06","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","1910.74","1019.06","2344.84","74","1095","1718.06","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","AETNA [1001]","HB CH AETNA HMO / PPO","640.92","58.3","","1530.90","1160.93","1884.08","89","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","582.66","53","","5253.92","5253.92","5253.92","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","637.62","58","","12181.47","12181.47","12181.47","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","687.09","62.5","","1350.68","1350.68","1350.68","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.66","44.45","","1910.74","891.94","1910.74","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","WELLPOINT [1015]","HB CH WELLPOINT","856.50","77.91","","1829.79","1561.50","2617.12","88","488.66","856.5","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.91","59.3","","1359.46","1201.30","1689.00","61","549.68","862.44","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","651.91","59.3","","1718.92","1718.92","1718.92","1 through 10","549.68","862.44","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.44","78.45","","1910.74","1019.06","2344.84","74","549.68","862.44","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","AETNA [1001]","HB CH AETNA HMO / PPO","1775.85","58.3","","1530.90","1160.93","1884.08","89","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1614.41","53","","5253.92","5253.92","5253.92","1 through 10","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1766.71","58","","12181.47","12181.47","12181.47","1 through 10","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1903.78","62.5","","1350.68","1350.68","1350.68","1 through 10","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1353.97","44.45","","1910.74","891.94","1910.74","1 through 10","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","WELLPOINT [1015]","HB CH WELLPOINT","2373.18","77.91","","1829.79","1561.50","2617.12","88","1353.97","2373.18","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1359.46","1201.30","1689.00","61","1523.03","2389.63","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1718.92","1718.92","1718.92","1 through 10","1523.03","2389.63","percent of total billed charges",""
"HIP LINER SZ B 36MM ACETABULAR DUAL G7 MOBILITY","SUP-ITM-10201676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2389.63","78.45","","1910.74","1019.06","2344.84","74","1523.03","2389.63","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","AETNA [1001]","HB CH AETNA HMO / PPO","640.92","58.3","","1530.90","1160.93","1884.08","89","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","582.66","53","","5253.92","5253.92","5253.92","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","637.62","58","","12181.47","12181.47","12181.47","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","687.09","62.5","","1350.68","1350.68","1350.68","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.66","44.45","","1910.74","891.94","1910.74","1 through 10","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","WELLPOINT [1015]","HB CH WELLPOINT","856.50","77.91","","1829.79","1561.50","2617.12","88","488.66","856.5","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.91","59.3","","1359.46","1201.30","1689.00","61","549.68","862.44","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","651.91","59.3","","1718.92","1718.92","1718.92","1 through 10","549.68","862.44","percent of total billed charges",""
"HIP LINER SZ F 36MM PLUS 5MM NEUTRAL G7 ARCOMXL","SUP-ITM-10201636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.44","78.45","","1910.74","1019.06","2344.84","74","549.68","862.44","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","AETNA [1001]","HB CH AETNA HMO / PPO","1662.76","58.3","","1530.90","1160.93","1884.08","89","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1511.60","53","","5253.92","5253.92","5253.92","1 through 10","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1654.20","58","","12181.47","12181.47","12181.47","1 through 10","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1782.54","62.5","","1350.68","1350.68","1350.68","1 through 10","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1267.75","44.45","","1910.74","891.94","1910.74","1 through 10","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","WELLPOINT [1015]","HB CH WELLPOINT","2222.05","77.91","","1829.79","1561.50","2617.12","88","1267.75","2222.05","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1691.28","59.3","","1359.46","1201.30","1689.00","61","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1691.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYED SS STANDARD BARREL","SUP-ITM-10034637","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2237.45","78.45","","1910.74","1019.06","2344.84","74","1426.04","2237.45","percent of total billed charges",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","78282.13","58711.60","MEDICARE [2001]","HB NWH MEDICARE","27342.10","","Case rate ($27,342.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,545.37, add-ons for qualifying new technology services are included. If operating cost exceeds $70,687.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,842.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,441.78. The transfer operating threshold is the transfer adjustment factor * $25,545.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,900.33. The transfer capital threshold is the transfer adjustment factor * $1,900.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","27818.41","22883.40","27868.42","12","24369.85","28823.4683","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","78282.13","58711.60","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","24369.85","","Case rate ($24,867.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,545.37, add-ons for qualifying new technology services are included. If operating cost exceeds $70,687.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,842.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,966.87. The transfer operating threshold is the transfer adjustment factor * $25,545.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,900.33. The transfer capital threshold is the transfer adjustment factor * $1,900.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","24879.71","24852.25","24883.86","1 through 10","24369.85","28823.4683","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","65770.57","49327.93","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","18898.04","","Case rate ($18,347.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,847.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,990.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,344.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,945.49. The transfer operating threshold is the transfer adjustment factor * $18,847.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.10. The transfer capital threshold is the transfer adjustment factor * $1,402.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","18870.49","18870.49","18870.49","1 through 10","17980.66","21738.19","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","65770.57","49327.93","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","20173.65","","Case rate ($20,173.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,847.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,990.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,344.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,771.54. The transfer operating threshold is the transfer adjustment factor * $18,847.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.10. The transfer capital threshold is the transfer adjustment factor * $1,402.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","18179.12","18179.12","18179.12","1 through 10","17980.66","21738.19","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","65770.57","49327.93","MEDICARE [2001]","HB NWH MEDICARE","20173.65","","Case rate ($20,173.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,847.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,990.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,344.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,771.54. The transfer operating threshold is the transfer adjustment factor * $18,847.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.10. The transfer capital threshold is the transfer adjustment factor * $1,402.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","20120.06","20119.80","20156.24","35","17980.66","21738.19","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","65770.57","49327.93","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","17980.66","","Case rate ($18,347.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,847.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,990.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,344.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,945.49. The transfer operating threshold is the transfer adjustment factor * $18,847.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.10. The transfer capital threshold is the transfer adjustment factor * $1,402.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17973.29","17973.03","18004.29","1 through 10","17980.66","21738.19","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","65770.57","49327.93","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17980.66","","Case rate ($18,347.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,847.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,990.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,344.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,945.49. The transfer operating threshold is the transfer adjustment factor * $18,847.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.10. The transfer capital threshold is the transfer adjustment factor * $1,402.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17974.74","17969.29","18006.79","1 through 10","17980.66","21738.19","other","Inpatient DRG"
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","1138.60","58.3","","1530.90","1160.93","1884.08","89","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1035.09","53","","5253.92","5253.92","5253.92","1 through 10","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1132.74","58","","12181.47","12181.47","12181.47","1 through 10","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1220.63","62.5","","1350.68","1350.68","1350.68","1 through 10","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","868.11","44.45","","1910.74","891.94","1910.74","1 through 10","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","WELLPOINT [1015]","HB CH WELLPOINT","1521.58","77.91","","1829.79","1561.50","2617.12","88","868.11","1521.58","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1359.46","1201.30","1689.00","61","976.5","1532.13","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1718.92","1718.92","1718.92","1 through 10","976.5","1532.13","percent of total billed charges",""
"HIP SHELL SIZE 55 POLARCUP SS UNCOATED POLISHED CEMENT USE","SUP-ITM-10198424","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1532.13","78.45","","1910.74","1019.06","2344.84","74","976.5","1532.13","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1530.90","1160.93","1884.08","89","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","5253.92","5253.92","5253.92","1 through 10","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","12181.47","12181.47","12181.47","1 through 10","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","1350.68","1350.68","1350.68","1 through 10","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1910.74","891.94","1910.74","1 through 10","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","1829.79","1561.50","2617.12","88","33.34","58.43","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1359.46","1201.30","1689.00","61","37.5","58.84","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","1718.92","1718.92","1718.92","1 through 10","37.5","58.84","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1910.74","1019.06","2344.84","74","37.5","58.84","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1530.90","1160.93","1884.08","89","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","5253.92","5253.92","5253.92","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","12181.47","12181.47","12181.47","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","1350.68","1350.68","1350.68","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1910.74","891.94","1910.74","1 through 10","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","1829.79","1561.50","2617.12","88","66.68","116.87","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1359.46","1201.30","1689.00","61","75","117.68","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","1718.92","1718.92","1718.92","1 through 10","75","117.68","percent of total billed charges",""
"HIP STEM 10MM CENTRALIZER CEMENTRALIZER POLYMER PROSTALAC","SUP-ITM-10013057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1910.74","1019.06","2344.84","74","75","117.68","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","AETNA [1001]","HB CH AETNA HMO / PPO","2203.74","58.3","","1530.90","1160.93","1884.08","89","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2003.40","53","","5253.92","5253.92","5253.92","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2192.40","58","","12181.47","12181.47","12181.47","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2362.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1680.21","44.45","","1910.74","891.94","1910.74","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","WELLPOINT [1015]","HB CH WELLPOINT","2945.00","77.91","","1829.79","1561.50","2617.12","88","1680.21","2945","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2241.54","59.3","","1359.46","1201.30","1689.00","61","1890","2965.41","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2241.54","59.3","","1718.92","1718.92","1718.92","1 through 10","1890","2965.41","percent of total billed charges",""
"HIP STEM 120MM 12/14 SZ 11 FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STANDARD","SUP-ITM-10030154","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2965.41","78.45","","1910.74","1019.06","2344.84","74","1890","2965.41","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1530.90","1160.93","1884.08","89","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","5253.92","5253.92","5253.92","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2713.24","58","","12181.47","12181.47","12181.47","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2923.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2079.37","44.45","","1910.74","891.94","1910.74","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","1829.79","1561.50","2617.12","88","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1359.46","1201.30","1689.00","61","2339","3669.89","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1718.92","1718.92","1718.92","1 through 10","2339","3669.89","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","1910.74","1019.06","2344.84","74","2339","3669.89","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 125MM SZ 20 TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10169045","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 129MM SZ 22 FEMORAL TAPERLOC PPS COATED COMPLETE MICROPLASTY HIGH OFFSET TYPE 1","SUP-ITM-10202948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","AETNA [1001]","HB CH AETNA HMO / PPO","2237.55","58.3","","1530.90","1160.93","1884.08","89","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2034.14","53","","5253.92","5253.92","5253.92","1 through 10","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2226.04","58","","12181.47","12181.47","12181.47","1 through 10","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2398.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.99","44.45","","1910.74","891.94","1910.74","1 through 10","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","WELLPOINT [1015]","HB CH WELLPOINT","2990.19","77.91","","1829.79","1561.50","2617.12","88","1705.99","2990.19","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3838.00","2878.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2275.93","59.3","","1359.46","1201.30","1689.00","61","1919","3010.91","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3838.00","2878.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2275.93","59.3","","1718.92","1718.92","1718.92","1 through 10","1919","3010.91","percent of total billed charges",""
"HIP STEM 12MM LATERAL SL PLUS","SUP-ITM-10198531","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3838.00","2878.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3010.91","78.45","","1910.74","1019.06","2344.84","74","1919","3010.91","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","AETNA [1001]","HB CH AETNA HMO / PPO","2203.74","58.3","","1530.90","1160.93","1884.08","89","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2003.40","53","","5253.92","5253.92","5253.92","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2192.40","58","","12181.47","12181.47","12181.47","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2362.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1680.21","44.45","","1910.74","891.94","1910.74","1 through 10","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","WELLPOINT [1015]","HB CH WELLPOINT","2945.00","77.91","","1829.79","1561.50","2617.12","88","1680.21","2945","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2241.54","59.3","","1359.46","1201.30","1689.00","61","1890","2965.41","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2241.54","59.3","","1718.92","1718.92","1718.92","1 through 10","1890","2965.41","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL VERSYS ADVOCATE ZIMALOY COBALT CEMENTED STD","SUP-ITM-10200957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2965.41","78.45","","1910.74","1019.06","2344.84","74","1890","2965.41","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 15.0X129MM TIVANIUM TITANIUM ALLOY COLLARLESS POROUS 12 14 TAPER REDUCED EXTENDED BX/1EA","SUP-ITM-10016369","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1530.90","1160.93","1884.08","89","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","5253.92","5253.92","5253.92","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2713.24","58","","12181.47","12181.47","12181.47","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2923.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2079.37","44.45","","1910.74","891.94","1910.74","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","1829.79","1561.50","2617.12","88","2079.37","3644.63","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1359.46","1201.30","1689.00","61","2339","3669.89","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1718.92","1718.92","1718.92","1 through 10","2339","3669.89","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","1910.74","1019.06","2344.84","74","2339","3669.89","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"HIP STEM 35X105MM SIZE 4 132DEG FEMORAL ACCOLADE TITANIUM HYDROXYAPATITE COATING","SUP-ITM-10100423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","AETNA [1001]","HB CH AETNA HMO / PPO","1469.16","58.3","","1530.90","1160.93","1884.08","89","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1335.60","53","","5253.92","5253.92","5253.92","1 through 10","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1461.60","58","","12181.47","12181.47","12181.47","1 through 10","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1575.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1120.14","44.45","","1910.74","891.94","1910.74","1 through 10","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","WELLPOINT [1015]","HB CH WELLPOINT","1963.33","77.91","","1829.79","1561.50","2617.12","88","1120.14","1963.33","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1494.36","59.3","","1359.46","1201.30","1689.00","61","1260","1976.94","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1494.36","59.3","","1718.92","1718.92","1718.92","1 through 10","1260","1976.94","percent of total billed charges",""
"HIP STEM 9.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1976.94","78.45","","1910.74","1019.06","2344.84","74","1260","1976.94","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1530.90","1160.93","1884.08","89","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","5253.92","5253.92","5253.92","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","12181.47","12181.47","12181.47","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1910.74","891.94","1910.74","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","1829.79","1561.50","2617.12","88","1600.2","2804.76","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1359.46","1201.30","1689.00","61","1800","2824.2","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1800","2824.2","percent of total billed charges",""
"HIP STEM 99MM SZ 2 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10090264","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1910.74","1019.06","2344.84","74","1800","2824.2","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1530.90","1160.93","1884.08","89","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","5253.92","5253.92","5253.92","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","12181.47","12181.47","12181.47","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1910.74","891.94","1910.74","1 through 10","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","1829.79","1561.50","2617.12","88","1600.2","2804.76","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1359.46","1201.30","1689.00","61","1800","2824.2","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1800","2824.2","percent of total billed charges",""
"HIP STEM LATERAL SZ 1 CONE 12/14 POLARSTEM CEMENTED","SUP-ITM-10330087","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1910.74","1019.06","2344.84","74","1800","2824.2","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1530.90","1160.93","1884.08","89","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","5253.92","5253.92","5253.92","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2713.24","58","","12181.47","12181.47","12181.47","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2923.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2079.37","44.45","","1910.74","891.94","1910.74","1 through 10","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","1829.79","1561.50","2617.12","88","2079.37","3644.63","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1359.46","1201.30","1689.00","61","2339","3669.89","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1718.92","1718.92","1718.92","1 through 10","2339","3669.89","percent of total billed charges",""
"HIP STEM SIZE 13 REVISION CORAIL STANDARD","SUP-ITM-10197868","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","1910.74","1019.06","2344.84","74","2339","3669.89","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1530.90","1160.93","1884.08","89","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","5253.92","5253.92","5253.92","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.00","58","","12181.47","12181.47","12181.47","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.55","44.45","","1910.74","891.94","1910.74","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","1829.79","1561.50","2617.12","88","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1359.46","1201.30","1689.00","61","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 10 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","1910.74","1019.06","2344.84","74","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 2 38MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","AETNA [1001]","HB CH AETNA HMO / PPO","1974.62","58.3","","1530.90","1160.93","1884.08","89","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1795.11","53","","5253.92","5253.92","5253.92","1 through 10","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1964.46","58","","12181.47","12181.47","12181.47","1 through 10","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2116.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1505.52","44.45","","1910.74","891.94","1910.74","1 through 10","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","WELLPOINT [1015]","HB CH WELLPOINT","2638.81","77.91","","1829.79","1561.50","2617.12","88","1505.52","2638.81","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3387.00","2540.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2008.49","59.3","","1359.46","1201.30","1689.00","61","1693.5","2657.1","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3387.00","2540.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2008.49","59.3","","1718.92","1718.92","1718.92","1 through 10","1693.5","2657.1","percent of total billed charges",""
"HIP STEM SZ 4 114X35MM 130DEG FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3387.00","2540.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2657.10","78.45","","1910.74","1019.06","2344.84","74","1693.5","2657.1","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1530.90","1160.93","1884.08","89","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","5253.92","5253.92","5253.92","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","12181.47","12181.47","12181.47","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1910.74","891.94","1910.74","1 through 10","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1829.79","1561.50","2617.12","88","1833.56","3213.79","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1359.46","1201.30","1689.00","61","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 7 FEMORAL ANTHOLOGY AFIT HIGH OFFSET POROUS PLUS HA","SUP-ITM-10281568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1910.74","1019.06","2344.84","74","2062.5","3236.06","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1530.90","1160.93","1884.08","89","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","5253.92","5253.92","5253.92","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","12181.47","12181.47","12181.47","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1910.74","891.94","1910.74","1 through 10","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","1829.79","1561.50","2617.12","88","1925.24","3374.48","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1359.46","1201.30","1689.00","61","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1718.92","1718.92","1718.92","1 through 10","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 8 FEMORAL ARTICULATING ECHO B MTRC MP FP HO","SUP-ITM-10202551","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1910.74","1019.06","2344.84","74","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1530.90","1160.93","1884.08","89","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","5253.92","5253.92","5253.92","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.00","58","","12181.47","12181.47","12181.47","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.55","44.45","","1910.74","891.94","1910.74","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","1829.79","1561.50","2617.12","88","1733.55","3038.49","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1359.46","1201.30","1689.00","61","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","1910.74","1019.06","2344.84","74","1950","3059.55","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","AETNA [1001]","HB CH AETNA HMO / PPO","3999.38","58.3","","1530.90","1160.93","1884.08","89","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3635.80","53","","5253.92","5253.92","5253.92","1 through 10","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3978.80","58","","12181.47","12181.47","12181.47","1 through 10","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4287.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3049.27","44.45","","1910.74","891.94","1910.74","1 through 10","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","WELLPOINT [1015]","HB CH WELLPOINT","5344.63","77.91","","1829.79","1561.50","2617.12","88","3049.27","5344.63","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6860.00","5145.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4067.98","59.3","","1359.46","1201.30","1689.00","61","3430","5381.67","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6860.00","5145.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4067.98","59.3","","1718.92","1718.92","1718.92","1 through 10","3430","5381.67","percent of total billed charges",""
"HIP WEDGE 54MM LONG TAPERED INTERSPACE HIGH RELEASE","SUP-ITM-10197092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6860.00","5145.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5381.67","78.45","","1910.74","1019.06","2344.84","74","3430","5381.67","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","outpatient","","","244.00","183.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.69","59.3","","416.64","138.88","416.64","1 through 10","30.45","191.42","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","13.51","105.45","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","1 through 10","12.89","87.08","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003280","CDM","G0475","HCPCS","0300","RC","","","","both","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.24","44.45","","226.03","226.03","226.03","1 through 10","23.6","286.9","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003280","CDM","G0475","HCPCS","0300","RC","","","","outpatient","","","302.00","226.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","179.09","59.3","","172.28","172.28","172.28","13","23.19","236.92","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003280","CDM","G0475","HCPCS","0300","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.92","78.45","","226.03","133.95","226.03","16","23.19","236.92","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","147.42","147.42","147.42","446","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","189.80","189.80","189.80","1 through 10","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","166.70","166.70","166.70","1 through 10","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","TRICARE [160005]","HB NWH TRICARE","253.65","95","","29.02","27.57","29.02","1 through 10","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","199.89","118.46","199.89","13","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","199.89","199.89","199.89","1 through 10","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","both","","","267.00","200.25","WELLPOINT [1015]","HB CH WELLPOINT","208.02","77.91","","204.78","204.78","464.78","78","23.6","253.65","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","outpatient","","","267.00","200.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.33","59.3","","152.36","152.36","152.36","362","23.19","209.46","percent of total billed charges",""
"Hiv Antigen/Antibody, Combination Assay, Screening","PX-30003493","CDM","87389","CPT","0302","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","199.89","118.46","199.89","333","23.19","209.46","percent of total billed charges",""
"Hiv With Extensive O.R. Procedures With McC","969","MS-DRG","","","","","","","","inpatient","","","64206.70","48155.02","MEDICARE [2001]","HB NWH MEDICARE","58312.74","","Case rate ($58,312.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $54,480.82, add-ons for qualifying new technology services are included. If operating cost exceeds $99,623.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,994.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.7. The base transfer operating payment is the transfer adjustment factor * $54,259.90. The transfer operating threshold is the transfer adjustment factor * $54,480.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,052.84. The transfer capital threshold is the transfer adjustment factor * $4,052.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","60468.71","60468.71","60468.71","1 through 10","51973.8","62835.14","other","Inpatient DRG"
"Hiv With Major Hiv Related Condition,MODERATE","892","DRG","","","","","","","","inpatient","","","30628.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18768.24","","Standard inlier is a Case rate ($18,768.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,572, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,664.07) for the length of stay and the standard reimbursement.","18768.24","18768.24","18768.24","1 through 10","8221.91","43735.76","case rate",""
"Hiv With Major Related Condition With McC","974","MS-DRG","","","","","","","","inpatient","","","62119.62","46589.71","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","25754.21","","Case rate ($25,004.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,685.99, add-ons for qualifying new technology services are included. If operating cost exceeds $70,828.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,852.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $23,093.30. The transfer operating threshold is the transfer adjustment factor * $25,685.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,910.79. The transfer capital threshold is the transfer adjustment factor * $1,910.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","26765.97","26765.97","26765.97","1 through 10","24504.01","29624.79","other","Inpatient DRG"
"Hiv With Major Related Condition With McC","974","MS-DRG","","","","","","","","inpatient","","","62119.62","46589.71","MOLINA [1014]","HB NWH MEDICARE","25004.09","","Case rate ($25,004.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $25,685.99, add-ons for qualifying new technology services are included. If operating cost exceeds $70,828.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,852.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $23,093.30. The transfer operating threshold is the transfer adjustment factor * $25,685.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,910.79. The transfer capital threshold is the transfer adjustment factor * $1,910.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25486.79","25486.79","25486.79","1 through 10","24504.01","29624.79","other","Inpatient Replacement Plans DRG"
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","198414.12","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","29452.48","","Case rate ($31,730.40). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $74,160.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","39502.62","39502.62","39502.62","1 through 10","27158.91","137011.2","case rate",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","","","","inpatient","","","30628.88","22971.66","MEDICARE [2001]","HB NWH MEDICARE","11243.18","","Case rate ($11,243.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,549.80, add-ons for qualifying new technology services are included. If operating cost exceeds $56,692.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,801.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,383.98. The transfer operating threshold is the transfer adjustment factor * $11,549.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $859.19. The transfer capital threshold is the transfer adjustment factor * $859.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59099.48","59099.48","59099.48","1 through 10","11018.32","13320.89","other","Inpatient Replacement Plans DRG"
"Hla Typing I High Res 1 Allele","PX-30000769","CDM","81381","CPT","0310","RC","","","","both","","","700.00","525.00","AETNA [1001]","HB CH AETNA HMO / PPO","408.10","58.3","","386.13","386.13","386.13","1 through 10","166.5","902.17","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","outpatient","","","985.00","738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.11","59.3","","561.39","561.39","561.39","1 through 10","372.03","772.73","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","outpatient","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","772.73","78.45","","1473.02","436.47","1473.02","1 through 10","372.03","772.73","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","both","","","211.00","158.25","AETNA [1001]","HB CH AETNA HMO / PPO","123.01","58.3","","116.24","116.24","116.24","1 through 10","25.29","200.45","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","211.00","158.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.12","59.3","","120.13","120.13","120.13","11","26.61","165.53","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","165.53","78.45","","157.60","93.40","157.60","1 through 10","26.61","165.53","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","131.79","60.5","","137.24","137.24","137.24","1 through 10","96.83","613.61","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","AETNA [1001]","HB CH AETNA HMO / PPO","213.96","58.3","","407.67","167.47","407.67","1 through 10","163.13","528.85","percent of total billed charges",""
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","43","163.13","528.85","other","OPPS APC"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","CHAMPVA [160001]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","171.38","171.38","171.38","1 through 10","163.13","528.85","other","Tricare OPPS"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","HUMANA [1012]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.89","182.89","182.89","1 through 10","163.13","528.85","other","OPPS APC"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","163.13","528.85","other","OPPS APC"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","TRICARE [160005]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","161.95","161.95","185.81","1 through 10","163.13","528.85","other","Tricare OPPS"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","182.09","182.49","20","163.13","528.85","other","OPPS APC"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.13","44.45","","327.58","327.58","327.58","1 through 10","163.13","528.85","percent of total billed charges",""
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","168.08","183.10","31","163.13","528.85","other","OPPS APC"
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","both","","","367.00","275.25","WELLPOINT [1015]","HB CH WELLPOINT","285.93","77.91","","566.28","566.28","566.28","25","163.13","528.85","percent of total billed charges",""
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","outpatient","","","367.00","275.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.63","59.3","","421.33","421.33","421.33","60","183.5","986.85","percent of total billed charges",""
"Home Sleep Test/Type 3 Porta","PX-98302109","CDM","G0399","HCPCS","0983","RC","","","","outpatient","","","367.00","275.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.91","78.45","","552.77","327.58","552.77","78","183.5","986.85","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","AETNA [1001]","HB CH AETNA HMO / PPO","430.84","58.3","","407.67","167.47","407.67","1 through 10","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","43","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","CHAMPVA [160001]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","171.38","171.38","171.38","1 through 10","176.52","575.75","other","Tricare OPPS"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","HUMANA [1012]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.89","182.89","182.89","1 through 10","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","TRICARE [160005]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","161.95","161.95","185.81","1 through 10","176.52","575.75","other","Tricare OPPS"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","182.09","182.49","20","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.49","44.45","","327.58","327.58","327.58","1 through 10","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","168.08","183.10","31","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","WELLPOINT [1015]","HB CH WELLPOINT","575.75","77.91","","566.28","566.28","566.28","25","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","739.00","554.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","438.23","59.3","","421.33","421.33","421.33","60","335.8","986.85","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","579.75","78.45","","552.77","327.58","552.77","78","335.8","986.85","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","AETNA [1001]","HB CH AETNA HMO / PPO","430.84","58.3","","407.67","167.47","407.67","1 through 10","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","43","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","CHAMPVA [160001]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","171.38","171.38","171.38","1 through 10","176.52","575.75","other","Tricare OPPS"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","HUMANA [1012]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.89","182.89","182.89","1 through 10","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","TRICARE [160005]","HB NWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","161.95","161.95","185.81","1 through 10","176.52","575.75","other","Tricare OPPS"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","182.09","182.49","20","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.49","44.45","","327.58","327.58","327.58","1 through 10","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","168.08","183.10","31","176.52","575.75","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","both","","","739.00","554.25","WELLPOINT [1015]","HB CH WELLPOINT","575.75","77.91","","566.28","566.28","566.28","25","176.52","575.75","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","739.00","554.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","438.23","59.3","","421.33","421.33","421.33","60","335.8","986.85","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000050","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","579.75","78.45","","552.77","327.58","552.77","78","335.8","986.85","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","196.00","147.00","AETNA [1001]","HB CH AETNA HMO / PPO","114.27","58.3","","108.30","108.30","108.30","25","17.56","186.2","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.12","44.45","","146.84","87.02","146.84","1 through 10","17.56","186.2","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","196.00","147.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.23","59.3","","111.93","111.93","111.93","41","17.39","153.76","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","153.76","78.45","","146.84","87.02","146.84","34","17.39","153.76","percent of total billed charges",""
"Homovanillic Acid (Hva)","PX-30000514","CDM","83150","CPT","0301","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","111.48","111.48","111.48","1 through 10","19.95","121.95","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","464.71","67.87","1012.10","221","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","293.04","293.04","293.04","11","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","983.89","983.89","983.89","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","677.18","677.18","677.18","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","46.58","46.58","46.58","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","747.15","747.15","747.15","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1141.67","481.21","1141.67","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","76.54","76.54","76.54","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","273.64","94.28","1367.51","138","1666.88","2921.63","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","720.78","230.14","2010.94","427","1875","2941.88","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","344.45","344.45","344.45","1 through 10","1875","2941.88","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1875","2941.88","percent of total billed charges",""
"HUMERAL ADAPTER TRAY +0","SUP-ITM-10327711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","456.17","105.33","1284.66","242","1875","2941.88","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","AETNA [1001]","HB CH AETNA HMO / PPO","999.03","58.3","","1530.90","1160.93","1884.08","89","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","908.21","53","","5253.92","5253.92","5253.92","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","993.89","58","","12181.47","12181.47","12181.47","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1071.00","62.5","","1350.68","1350.68","1350.68","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.70","44.45","","1910.74","891.94","1910.74","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","WELLPOINT [1015]","HB CH WELLPOINT","1335.07","77.91","","1829.79","1561.50","2617.12","88","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1359.46","1201.30","1689.00","61","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1718.92","1718.92","1718.92","1 through 10","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1344.32","78.45","","1910.74","1019.06","2344.84","74","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","AETNA [1001]","HB CH AETNA HMO / PPO","999.03","58.3","","1530.90","1160.93","1884.08","89","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","908.21","53","","5253.92","5253.92","5253.92","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","993.89","58","","12181.47","12181.47","12181.47","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1071.00","62.5","","1350.68","1350.68","1350.68","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.70","44.45","","1910.74","891.94","1910.74","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","WELLPOINT [1015]","HB CH WELLPOINT","1335.07","77.91","","1829.79","1561.50","2617.12","88","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1359.46","1201.30","1689.00","61","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1718.92","1718.92","1718.92","1 through 10","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1344.32","78.45","","1910.74","1019.06","2344.84","74","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","AETNA [1001]","HB CH AETNA HMO / PPO","999.03","58.3","","1530.90","1160.93","1884.08","89","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","908.21","53","","5253.92","5253.92","5253.92","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","993.89","58","","12181.47","12181.47","12181.47","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1071.00","62.5","","1350.68","1350.68","1350.68","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.70","44.45","","1910.74","891.94","1910.74","1 through 10","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","WELLPOINT [1015]","HB CH WELLPOINT","1335.07","77.91","","1829.79","1561.50","2617.12","88","761.7","1335.07","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1359.46","1201.30","1689.00","61","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1718.92","1718.92","1718.92","1 through 10","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1344.32","78.45","","1910.74","1019.06","2344.84","74","856.8","1344.32","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","AETNA [1001]","HB CH AETNA HMO / PPO","2464.92","58.3","","1530.90","1160.93","1884.08","89","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2240.84","53","","5253.92","5253.92","5253.92","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2452.24","58","","12181.47","12181.47","12181.47","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2642.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1879.35","44.45","","1910.74","891.94","1910.74","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB CH WELLPOINT","3294.03","77.91","","1829.79","1561.50","2617.12","88","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1359.46","1201.30","1689.00","61","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3316.87","78.45","","1910.74","1019.06","2344.84","74","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","AETNA [1001]","HB CH AETNA HMO / PPO","2464.92","58.3","","1530.90","1160.93","1884.08","89","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2240.84","53","","5253.92","5253.92","5253.92","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2452.24","58","","12181.47","12181.47","12181.47","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2642.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1879.35","44.45","","1910.74","891.94","1910.74","1 through 10","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB CH WELLPOINT","3294.03","77.91","","1829.79","1561.50","2617.12","88","1879.35","3294.03","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1359.46","1201.30","1689.00","61","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3316.87","78.45","","1910.74","1019.06","2344.84","74","2114","3316.87","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","AETNA [1001]","HB CH AETNA HMO / PPO","951.46","58.3","","1530.90","1160.93","1884.08","89","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.96","53","","5253.92","5253.92","5253.92","1 through 10","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","946.56","58","","12181.47","12181.47","12181.47","1 through 10","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1020.00","62.5","","1350.68","1350.68","1350.68","1 through 10","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.42","44.45","","1910.74","891.94","1910.74","1 through 10","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","WELLPOINT [1015]","HB CH WELLPOINT","1271.49","77.91","","1829.79","1561.50","2617.12","88","725.42","1271.49","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.78","59.3","","1359.46","1201.30","1689.00","61","816","1280.3","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","967.78","59.3","","1718.92","1718.92","1718.92","1 through 10","816","1280.3","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.30","78.45","","1910.74","1019.06","2344.84","74","816","1280.3","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","AETNA [1001]","HB CH AETNA HMO / PPO","1304.75","58.3","","1530.90","1160.93","1884.08","89","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1186.14","53","","5253.92","5253.92","5253.92","1 through 10","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1298.04","58","","12181.47","12181.47","12181.47","1 through 10","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1398.75","62.5","","1350.68","1350.68","1350.68","1 through 10","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","994.79","44.45","","1910.74","891.94","1910.74","1 through 10","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","WELLPOINT [1015]","HB CH WELLPOINT","1743.63","77.91","","1829.79","1561.50","2617.12","88","994.79","1743.63","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2238.00","1678.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1327.13","59.3","","1359.46","1201.30","1689.00","61","1119","1755.71","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2238.00","1678.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1327.13","59.3","","1718.92","1718.92","1718.92","1 through 10","1119","1755.71","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2238.00","1678.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1755.71","78.45","","1910.74","1019.06","2344.84","74","1119","1755.71","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1530.90","1160.93","1884.08","89","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","5253.92","5253.92","5253.92","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.00","58","","12181.47","12181.47","12181.47","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.55","44.45","","1910.74","891.94","1910.74","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","1829.79","1561.50","2617.12","88","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1359.46","1201.30","1689.00","61","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD 19X50MM IDENTITY CR MEDIAL STEMLESS","SUP-ITM-10286914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","1910.74","1019.06","2344.84","74","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","AETNA [1001]","HB CH AETNA HMO / PPO","3138.29","58.3","","1530.90","1160.93","1884.08","89","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2852.99","53","","5253.92","5253.92","5253.92","1 through 10","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3122.14","58","","12181.47","12181.47","12181.47","1 through 10","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3364.38","62.5","","1350.68","1350.68","1350.68","1 through 10","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2392.74","44.45","","1910.74","891.94","1910.74","1 through 10","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","WELLPOINT [1015]","HB CH WELLPOINT","4193.90","77.91","","1829.79","1561.50","2617.12","88","2392.74","4193.9","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3192.12","59.3","","1359.46","1201.30","1689.00","61","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3192.12","59.3","","1718.92","1718.92","1718.92","1 through 10","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4222.96","78.45","","1910.74","1019.06","2344.84","74","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","464.71","67.87","1012.10","221","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","293.04","293.04","293.04","11","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","983.89","983.89","983.89","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","677.18","677.18","677.18","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","46.58","46.58","46.58","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","747.15","747.15","747.15","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1141.67","481.21","1141.67","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","76.54","76.54","76.54","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","273.64","94.28","1367.51","138","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","720.78","230.14","2010.94","427","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","344.45","344.45","344.45","1 through 10","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1120.13","1120.13","1120.13","1 through 10","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","456.17","105.33","1284.66","242","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"HUMERAL HEAD 39/16 ECLIPSE","SUP-ITM-10274252","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","AETNA [1001]","HB CH AETNA HMO / PPO","2506.90","58.3","","1530.90","1160.93","1884.08","89","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2279.00","53","","5253.92","5253.92","5253.92","1 through 10","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2494.00","58","","12181.47","12181.47","12181.47","1 through 10","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1911.35","44.45","","1910.74","891.94","1910.74","1 through 10","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","WELLPOINT [1015]","HB CH WELLPOINT","3350.13","77.91","","1829.79","1561.50","2617.12","88","1911.35","3350.13","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2549.90","59.3","","1359.46","1201.30","1689.00","61","2150","3373.35","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2549.90","59.3","","1718.92","1718.92","1718.92","1 through 10","2150","3373.35","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3373.35","78.45","","1910.74","1019.06","2344.84","74","2150","3373.35","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1530.90","1160.93","1884.08","89","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","5253.92","5253.92","5253.92","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","12181.47","12181.47","12181.47","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1910.74","891.94","1910.74","1 through 10","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","1829.79","1561.50","2617.12","88","1610.87","2823.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1359.46","1201.30","1689.00","61","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1718.92","1718.92","1718.92","1 through 10","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1910.74","1019.06","2344.84","74","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1530.90","1160.93","1884.08","89","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","5253.92","5253.92","5253.92","1 through 10","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","904.80","58","","12181.47","12181.47","12181.47","1 through 10","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","975.00","62.5","","1350.68","1350.68","1350.68","1 through 10","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.42","44.45","","1910.74","891.94","1910.74","1 through 10","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","1829.79","1561.50","2617.12","88","693.42","1215.4","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1359.46","1201.30","1689.00","61","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","925.08","59.3","","1718.92","1718.92","1718.92","1 through 10","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","1910.74","1019.06","2344.84","74","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1530.90","1160.93","1884.08","89","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","5253.92","5253.92","5253.92","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.00","58","","12181.47","12181.47","12181.47","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.55","44.45","","1910.74","891.94","1910.74","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","1829.79","1561.50","2617.12","88","1733.55","3038.49","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1359.46","1201.30","1689.00","61","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD 47MM STEMLESS EQUINOXE SHORT","SUP-ITM-10287921","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","1910.74","1019.06","2344.84","74","1950","3059.55","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2915.00","58.3","","1530.90","1160.93","1884.08","89","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.00","53","","5253.92","5253.92","5253.92","1 through 10","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2900.00","58","","12181.47","12181.47","12181.47","1 through 10","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2222.50","44.45","","1910.74","891.94","1910.74","1 through 10","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","1829.79","1561.50","2617.12","88","2222.5","3895.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1359.46","1201.30","1689.00","61","2500","3922.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2500","3922.5","percent of total billed charges",""
"HUMERAL HEAD MODULAR REMEDY 50MM","SUP-ITM-10294859","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3922.50","78.45","","1910.74","1019.06","2344.84","74","2500","3922.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","AETNA [1001]","HB CH AETNA HMO / PPO","1163.52","58.3","","1530.90","1160.93","1884.08","89","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1057.75","53","","5253.92","5253.92","5253.92","1 through 10","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1157.54","58","","12181.47","12181.47","12181.47","1 through 10","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1247.34","62.5","","1350.68","1350.68","1350.68","1 through 10","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","887.11","44.45","","1910.74","891.94","1910.74","1 through 10","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","WELLPOINT [1015]","HB CH WELLPOINT","1554.89","77.91","","1829.79","1561.50","2617.12","88","887.11","1554.89","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1359.46","1201.30","1689.00","61","997.88","1565.67","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1718.92","1718.92","1718.92","1 through 10","997.88","1565.67","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1565.67","78.45","","1910.74","1019.06","2344.84","74","997.88","1565.67","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","AETNA [1001]","HB CH AETNA HMO / PPO","1932.65","58.3","","1530.90","1160.93","1884.08","89","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1756.95","53","","5253.92","5253.92","5253.92","1 through 10","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1922.70","58","","12181.47","12181.47","12181.47","1 through 10","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2071.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1473.52","44.45","","1910.74","891.94","1910.74","1 through 10","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","WELLPOINT [1015]","HB CH WELLPOINT","2582.72","77.91","","1829.79","1561.50","2617.12","88","1473.52","2582.72","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1359.46","1201.30","1689.00","61","1657.5","2600.62","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1657.5","2600.62","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2600.62","78.45","","1910.74","1019.06","2344.84","74","1657.5","2600.62","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","AETNA [1001]","HB CH AETNA HMO / PPO","1226.05","58.3","","1530.90","1160.93","1884.08","89","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1114.59","53","","5253.92","5253.92","5253.92","1 through 10","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1219.74","58","","12181.47","12181.47","12181.47","1 through 10","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1314.38","62.5","","1350.68","1350.68","1350.68","1 through 10","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","934.78","44.45","","1910.74","891.94","1910.74","1 through 10","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","WELLPOINT [1015]","HB CH WELLPOINT","1638.45","77.91","","1829.79","1561.50","2617.12","88","934.78","1638.45","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2103.00","1577.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1247.08","59.3","","1359.46","1201.30","1689.00","61","1051.5","1649.8","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2103.00","1577.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1247.08","59.3","","1718.92","1718.92","1718.92","1 through 10","1051.5","1649.8","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2103.00","1577.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1649.80","78.45","","1910.74","1019.06","2344.84","74","1051.5","1649.8","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 6 12.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136044","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","1530.90","1160.93","1884.08","89","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.10","53","","5253.92","5253.92","5253.92","1 through 10","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","852.60","58","","12181.47","12181.47","12181.47","1 through 10","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","918.75","62.5","","1350.68","1350.68","1350.68","1 through 10","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","1910.74","891.94","1910.74","1 through 10","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","1829.79","1561.50","2617.12","88","653.42","1145.28","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","1359.46","1201.30","1689.00","61","735","1153.22","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","871.71","59.3","","1718.92","1718.92","1718.92","1 through 10","735","1153.22","percent of total billed charges",""
"HUMERAL SPACER 33 +12MM OSTEOCONDUCTIVE MATERIAL","SUP-ITM-10321559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","1910.74","1019.06","2344.84","74","735","1153.22","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","1530.90","1160.93","1884.08","89","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","5253.92","5253.92","5253.92","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1590.36","58","","12181.47","12181.47","12181.47","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1713.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1218.82","44.45","","1910.74","891.94","1910.74","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","1829.79","1561.50","2617.12","88","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1359.46","1201.30","1689.00","61","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1718.92","1718.92","1718.92","1 through 10","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","1910.74","1019.06","2344.84","74","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","AETNA [1001]","HB CH AETNA HMO / PPO","2576.86","58.3","","1530.90","1160.93","1884.08","89","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2342.60","53","","5253.92","5253.92","5253.92","1 through 10","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2563.60","58","","12181.47","12181.47","12181.47","1 through 10","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2762.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1964.69","44.45","","1910.74","891.94","1910.74","1 through 10","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","WELLPOINT [1015]","HB CH WELLPOINT","3443.62","77.91","","1829.79","1561.50","2617.12","88","1964.69","3443.62","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4420.00","3315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2621.06","59.3","","1359.46","1201.30","1689.00","61","2210","3467.49","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4420.00","3315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2621.06","59.3","","1718.92","1718.92","1718.92","1 through 10","2210","3467.49","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4420.00","3315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3467.49","78.45","","1910.74","1019.06","2344.84","74","2210","3467.49","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","AETNA [1001]","HB CH AETNA HMO / PPO","2060.91","58.3","","1530.90","1160.93","1884.08","89","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.55","53","","5253.92","5253.92","5253.92","1 through 10","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2050.30","58","","12181.47","12181.47","12181.47","1 through 10","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2209.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.31","44.45","","1910.74","891.94","1910.74","1 through 10","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","WELLPOINT [1015]","HB CH WELLPOINT","2754.12","77.91","","1829.79","1561.50","2617.12","88","1571.31","2754.12","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2096.26","59.3","","1359.46","1201.30","1689.00","61","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2096.26","59.3","","1718.92","1718.92","1718.92","1 through 10","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2773.21","78.45","","1910.74","1019.06","2344.84","74","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","AETNA [1001]","HB CH AETNA HMO / PPO","1647.56","58.3","","1530.90","1160.93","1884.08","89","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1497.78","53","","5253.92","5253.92","5253.92","1 through 10","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1639.08","58","","12181.47","12181.47","12181.47","1 through 10","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1766.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.16","44.45","","1910.74","891.94","1910.74","1 through 10","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","WELLPOINT [1015]","HB CH WELLPOINT","2201.74","77.91","","1829.79","1561.50","2617.12","88","1256.16","2201.74","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1675.82","59.3","","1359.46","1201.30","1689.00","61","1413","2217","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1675.82","59.3","","1718.92","1718.92","1718.92","1 through 10","1413","2217","percent of total billed charges",""
"HUMERAL STEM 12MM 135DEG GLOBAL UNITE ANATOMIC REVERSE","SUP-ITM-10136722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2217.00","78.45","","1910.74","1019.06","2344.84","74","1413","2217","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","1530.90","1160.93","1884.08","89","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","5253.92","5253.92","5253.92","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1590.36","58","","12181.47","12181.47","12181.47","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1713.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1218.82","44.45","","1910.74","891.94","1910.74","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","1829.79","1561.50","2617.12","88","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1359.46","1201.30","1689.00","61","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1718.92","1718.92","1718.92","1 through 10","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","1910.74","1019.06","2344.84","74","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","AETNA [1001]","HB CH AETNA HMO / PPO","3011.78","58.3","","1530.90","1160.93","1884.08","89","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2737.98","53","","5253.92","5253.92","5253.92","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2996.28","58","","12181.47","12181.47","12181.47","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3228.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2296.29","44.45","","1910.74","891.94","1910.74","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","WELLPOINT [1015]","HB CH WELLPOINT","4024.83","77.91","","1829.79","1561.50","2617.12","88","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1359.46","1201.30","1689.00","61","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1718.92","1718.92","1718.92","1 through 10","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 12X55MM COMPREHENSIVE MICRO","SUP-ITM-10121729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4052.73","78.45","","1910.74","1019.06","2344.84","74","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1530.90","1160.93","1884.08","89","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","5253.92","5253.92","5253.92","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2517.20","58","","12181.47","12181.47","12181.47","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2712.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.13","44.45","","1910.74","891.94","1910.74","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","1829.79","1561.50","2617.12","88","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1359.46","1201.30","1689.00","61","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1718.92","1718.92","1718.92","1 through 10","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10118168","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","1910.74","1019.06","2344.84","74","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1530.90","1160.93","1884.08","89","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","5253.92","5253.92","5253.92","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2517.20","58","","12181.47","12181.47","12181.47","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2712.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.13","44.45","","1910.74","891.94","1910.74","1 through 10","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","1829.79","1561.50","2617.12","88","1929.13","3381.29","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1359.46","1201.30","1689.00","61","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1718.92","1718.92","1718.92","1 through 10","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 14MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10079344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","1910.74","1019.06","2344.84","74","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","464.71","67.87","1012.10","221","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1598.59","58.3","","293.04","293.04","293.04","11","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","983.89","983.89","983.89","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1590.36","58","","677.18","677.18","677.18","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1713.75","62.5","","46.58","46.58","46.58","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","747.15","747.15","747.15","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1218.82","44.45","","1141.67","481.21","1141.67","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1218.82","44.45","","76.54","76.54","76.54","1 through 10","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","273.64","94.28","1367.51","138","1218.82","2136.29","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","720.78","230.14","2010.94","427","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1626.01","59.3","","344.45","344.45","344.45","1 through 10","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","456.17","105.33","1284.66","242","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1530.90","1160.93","1884.08","89","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","5253.92","5253.92","5253.92","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3132.00","58","","12181.47","12181.47","12181.47","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3375.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2400.30","44.45","","1910.74","891.94","1910.74","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","1829.79","1561.50","2617.12","88","2400.3","4207.14","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1359.46","1201.30","1689.00","61","2700","4236.3","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2700","4236.3","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","1910.74","1019.06","2344.84","74","2700","4236.3","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","AETNA [1001]","HB CH AETNA HMO / PPO","3011.78","58.3","","1530.90","1160.93","1884.08","89","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2737.98","53","","5253.92","5253.92","5253.92","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2996.28","58","","12181.47","12181.47","12181.47","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3228.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2296.29","44.45","","1910.74","891.94","1910.74","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","WELLPOINT [1015]","HB CH WELLPOINT","4024.83","77.91","","1829.79","1561.50","2617.12","88","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1359.46","1201.30","1689.00","61","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1718.92","1718.92","1718.92","1 through 10","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 7X122MM COMPREHENSIVE COBALT MACROBOND COATED STANDARD","SUP-ITM-10113682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4052.73","78.45","","1910.74","1019.06","2344.84","74","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","AETNA [1001]","HB CH AETNA HMO / PPO","3011.78","58.3","","1530.90","1160.93","1884.08","89","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2737.98","53","","5253.92","5253.92","5253.92","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2996.28","58","","12181.47","12181.47","12181.47","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3228.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2296.29","44.45","","1910.74","891.94","1910.74","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","WELLPOINT [1015]","HB CH WELLPOINT","4024.83","77.91","","1829.79","1561.50","2617.12","88","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1359.46","1201.30","1689.00","61","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1718.92","1718.92","1718.92","1 through 10","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 83X13MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4052.73","78.45","","1910.74","1019.06","2344.84","74","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","AETNA [1001]","HB CH AETNA HMO / PPO","2387.39","58.3","","1530.90","1160.93","1884.08","89","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2170.35","53","","5253.92","5253.92","5253.92","1 through 10","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2375.10","58","","12181.47","12181.47","12181.47","1 through 10","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2559.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.23","44.45","","1910.74","891.94","1910.74","1 through 10","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","WELLPOINT [1015]","HB CH WELLPOINT","3190.41","77.91","","1829.79","1561.50","2617.12","88","1820.23","3190.41","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2428.34","59.3","","1359.46","1201.30","1689.00","61","2047.5","3212.53","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2428.34","59.3","","1718.92","1718.92","1718.92","1 through 10","2047.5","3212.53","percent of total billed charges",""
"HUMERAL STEM 8X122MM COMPREHENSIVE FRACTURE PPS","SUP-ITM-10202105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3212.53","78.45","","1910.74","1019.06","2344.84","74","2047.5","3212.53","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","AETNA [1001]","HB CH AETNA HMO / PPO","3011.78","58.3","","1530.90","1160.93","1884.08","89","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2737.98","53","","5253.92","5253.92","5253.92","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2996.28","58","","12181.47","12181.47","12181.47","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3228.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2296.29","44.45","","1910.74","891.94","1910.74","1 through 10","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","WELLPOINT [1015]","HB CH WELLPOINT","4024.83","77.91","","1829.79","1561.50","2617.12","88","2296.29","4024.83","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1359.46","1201.30","1689.00","61","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1718.92","1718.92","1718.92","1 through 10","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 8X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4052.73","78.45","","1910.74","1019.06","2344.84","74","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","AETNA [1001]","HB CH AETNA HMO / PPO","6646.20","58.3","","1530.90","1160.93","1884.08","89","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6042.00","53","","5253.92","5253.92","5253.92","1 through 10","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6612.00","58","","12181.47","12181.47","12181.47","1 through 10","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5067.30","44.45","","1910.74","891.94","1910.74","1 through 10","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","11400.00","8550.00","WELLPOINT [1015]","HB CH WELLPOINT","8881.74","77.91","","1829.79","1561.50","2617.12","88","5067.3","8881.74","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11400.00","8550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6760.20","59.3","","1359.46","1201.30","1689.00","61","5700","8943.3","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11400.00","8550.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","6760.20","59.3","","1718.92","1718.92","1718.92","1 through 10","5700","8943.3","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11400.00","8550.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8943.30","78.45","","1910.74","1019.06","2344.84","74","5700","8943.3","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","AETNA [1001]","HB CH AETNA HMO / PPO","2801.90","58.3","","1530.90","1160.93","1884.08","89","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2547.18","53","","5253.92","5253.92","5253.92","1 through 10","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2787.48","58","","12181.47","12181.47","12181.47","1 through 10","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3003.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2136.27","44.45","","1910.74","891.94","1910.74","1 through 10","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","WELLPOINT [1015]","HB CH WELLPOINT","3744.35","77.91","","1829.79","1561.50","2617.12","88","2136.27","3744.35","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2849.96","59.3","","1359.46","1201.30","1689.00","61","2403","3770.31","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2849.96","59.3","","1718.92","1718.92","1718.92","1 through 10","2403","3770.31","percent of total billed charges",""
"HUMERAL STEM 9MM EQUINOXE PRESERVE PRESS FIT PLASMA COATED","SUP-ITM-10286915","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3770.31","78.45","","1910.74","1019.06","2344.84","74","2403","3770.31","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","AETNA [1001]","HB CH AETNA HMO / PPO","3206.50","58.3","","1530.90","1160.93","1884.08","89","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2915.00","53","","5253.92","5253.92","5253.92","1 through 10","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3190.00","58","","12181.47","12181.47","12181.47","1 through 10","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2444.75","44.45","","1910.74","891.94","1910.74","1 through 10","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB CH WELLPOINT","4285.05","77.91","","1829.79","1561.50","2617.12","88","2444.75","4285.05","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3261.50","59.3","","1359.46","1201.30","1689.00","61","2750","4314.75","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3261.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2750","4314.75","percent of total billed charges",""
"HUMERAL STEM MODULAR REMEDY MEDIUM","SUP-ITM-10294855","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4314.75","78.45","","1910.74","1019.06","2344.84","74","2750","4314.75","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","AETNA [1001]","HB CH AETNA HMO / PPO","2897.51","58.3","","1530.90","1160.93","1884.08","89","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2634.10","53","","5253.92","5253.92","5253.92","1 through 10","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2882.60","58","","12181.47","12181.47","12181.47","1 through 10","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3106.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2209.17","44.45","","1910.74","891.94","1910.74","1 through 10","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","WELLPOINT [1015]","HB CH WELLPOINT","3872.13","77.91","","1829.79","1561.50","2617.12","88","2209.17","3872.13","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2947.21","59.3","","1359.46","1201.30","1689.00","61","2485","3898.97","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2947.21","59.3","","1718.92","1718.92","1718.92","1 through 10","2485","3898.97","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3898.97","78.45","","1910.74","1019.06","2344.84","74","2485","3898.97","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1530.90","1160.93","1884.08","89","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","5253.92","5253.92","5253.92","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2361.63","58","","12181.47","12181.47","12181.47","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2544.86","62.5","","1350.68","1350.68","1350.68","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1809.91","44.45","","1910.74","891.94","1910.74","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","1829.79","1561.50","2617.12","88","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1359.46","1201.30","1689.00","61","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1718.92","1718.92","1718.92","1 through 10","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","1910.74","1019.06","2344.84","74","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1530.90","1160.93","1884.08","89","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","5253.92","5253.92","5253.92","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2361.63","58","","12181.47","12181.47","12181.47","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2544.86","62.5","","1350.68","1350.68","1350.68","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1809.91","44.45","","1910.74","891.94","1910.74","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","1829.79","1561.50","2617.12","88","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1359.46","1201.30","1689.00","61","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1718.92","1718.92","1718.92","1 through 10","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","1910.74","1019.06","2344.84","74","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1530.90","1160.93","1884.08","89","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","5253.92","5253.92","5253.92","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2361.63","58","","12181.47","12181.47","12181.47","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2544.86","62.5","","1350.68","1350.68","1350.68","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1809.91","44.45","","1910.74","891.94","1910.74","1 through 10","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","1829.79","1561.50","2617.12","88","1809.91","3172.32","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1359.46","1201.30","1689.00","61","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1718.92","1718.92","1718.92","1 through 10","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 9 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10134002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","1910.74","1019.06","2344.84","74","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1530.90","1160.93","1884.08","89","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","5253.92","5253.92","5253.92","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.00","58","","12181.47","12181.47","12181.47","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2437.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.55","44.45","","1910.74","891.94","1910.74","1 through 10","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","1829.79","1561.50","2617.12","88","1733.55","3038.49","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1359.46","1201.30","1689.00","61","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","1910.74","1019.06","2344.84","74","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","AETNA [1001]","HB CH AETNA HMO / PPO","4197.60","58.3","","1530.90","1160.93","1884.08","89","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3816.00","53","","5253.92","5253.92","5253.92","1 through 10","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4176.00","58","","12181.47","12181.47","12181.47","1 through 10","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3200.40","44.45","","1910.74","891.94","1910.74","1 through 10","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","WELLPOINT [1015]","HB CH WELLPOINT","5609.52","77.91","","1829.79","1561.50","2617.12","88","3200.4","5609.52","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4269.60","59.3","","1359.46","1201.30","1689.00","61","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4269.60","59.3","","1718.92","1718.92","1718.92","1 through 10","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM SYSTEM","SUP-ITM-10281792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5648.40","78.45","","1910.74","1019.06","2344.84","74","3600","5648.4","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","AETNA [1001]","HB CH AETNA HMO / PPO","1979.69","58.3","","1530.90","1160.93","1884.08","89","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1799.72","53","","5253.92","5253.92","5253.92","1 through 10","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1969.51","58","","12181.47","12181.47","12181.47","1 through 10","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2122.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1509.39","44.45","","1910.74","891.94","1910.74","1 through 10","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","WELLPOINT [1015]","HB CH WELLPOINT","2645.59","77.91","","1829.79","1561.50","2617.12","88","1509.39","2645.59","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2013.65","59.3","","1359.46","1201.30","1689.00","61","1697.85","2663.93","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2013.65","59.3","","1718.92","1718.92","1718.92","1 through 10","1697.85","2663.93","percent of total billed charges",""
"HUMERAL TRAY 40MM PLUS 3MM TAPER OFFSET STD","SUP-ITM-10282006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2663.93","78.45","","1910.74","1019.06","2344.84","74","1697.85","2663.93","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"HUMERUS HEAD 52X19MM PLATE BONE HUMERAL AEQUALIS TITANIUM HIGH OFFSET","SUP-ITM-10136071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","464.71","67.87","1012.10","221","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","293.04","293.04","293.04","11","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","983.89","983.89","983.89","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1506.49","58","","677.18","677.18","677.18","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1623.38","62.5","","46.58","46.58","46.58","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","747.15","747.15","747.15","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","1141.67","481.21","1141.67","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","76.54","76.54","76.54","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","273.64","94.28","1367.51","138","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","720.78","230.14","2010.94","427","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1540.26","59.3","","344.45","344.45","344.45","1 through 10","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","456.17","105.33","1284.66","242","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","AETNA [1001]","HB CH AETNA HMO / PPO","1718.78","58.3","","464.71","67.87","1012.10","221","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1718.78","58.3","","293.04","293.04","293.04","11","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1562.52","53","","983.89","983.89","983.89","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1709.93","58","","677.18","677.18","677.18","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1842.60","62.5","","46.58","46.58","46.58","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2152.16","73","","747.15","747.15","747.15","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1310.46","44.45","","1141.67","481.21","1141.67","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1310.46","44.45","","76.54","76.54","76.54","1 through 10","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2948.16","2211.12","WELLPOINT [1015]","HB CH WELLPOINT","2296.91","77.91","","273.64","94.28","1367.51","138","1310.46","2296.91","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2948.16","2211.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1748.26","59.3","","720.78","230.14","2010.94","427","1474.08","2312.83","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2948.16","2211.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1748.26","59.3","","344.45","344.45","344.45","1 through 10","1474.08","2312.83","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2948.16","2211.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2312.83","78.45","","1120.13","1120.13","1120.13","1 through 10","1474.08","2312.83","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X127MM LONG 7 HOLE VA LCP POSTEROLATERAL DISTAL LATERAL SUPPORT TITANIUM LEFT","SUP-ITM-10125534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2948.16","2211.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2312.83","78.45","","456.17","105.33","1284.66","242","1474.08","2312.83","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","AETNA [1001]","HB CH AETNA HMO / PPO","1581.59","58.3","","464.71","67.87","1012.10","221","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1581.59","58.3","","293.04","293.04","293.04","11","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1437.81","53","","983.89","983.89","983.89","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1573.45","58","","677.18","677.18","677.18","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1695.53","62.5","","46.58","46.58","46.58","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1980.37","73","","747.15","747.15","747.15","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1205.86","44.45","","1141.67","481.21","1141.67","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1205.86","44.45","","76.54","76.54","76.54","1 through 10","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","2712.84","2034.63","WELLPOINT [1015]","HB CH WELLPOINT","2113.57","77.91","","273.64","94.28","1367.51","138","1205.86","2113.57","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2712.84","2034.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","1608.71","59.3","","720.78","230.14","2010.94","427","1356.42","2128.22","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2712.84","2034.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1608.71","59.3","","344.45","344.45","344.45","1 through 10","1356.42","2128.22","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2712.84","2034.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2128.22","78.45","","1120.13","1120.13","1120.13","1 through 10","1356.42","2128.22","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2712.84","2034.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2128.22","78.45","","456.17","105.33","1284.66","242","1356.42","2128.22","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","464.71","67.87","1012.10","221","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","293.04","293.04","293.04","11","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","983.89","983.89","983.89","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1506.49","58","","677.18","677.18","677.18","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1623.38","62.5","","46.58","46.58","46.58","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","747.15","747.15","747.15","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","1141.67","481.21","1141.67","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","76.54","76.54","76.54","1 through 10","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","273.64","94.28","1367.51","138","1154.54","2023.63","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","720.78","230.14","2010.94","427","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1540.26","59.3","","344.45","344.45","344.45","1 through 10","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","456.17","105.33","1284.66","242","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","AETNA [1001]","HB CH AETNA HMO / PPO","1041.88","58.3","","464.71","67.87","1012.10","221","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1041.88","58.3","","293.04","293.04","293.04","11","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","947.16","53","","983.89","983.89","983.89","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1036.52","58","","677.18","677.18","677.18","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1116.94","62.5","","46.58","46.58","46.58","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1304.58","73","","747.15","747.15","747.15","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","794.37","44.45","","1141.67","481.21","1141.67","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","794.37","44.45","","76.54","76.54","76.54","1 through 10","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","WELLPOINT [1015]","HB CH WELLPOINT","1392.33","77.91","","273.64","94.28","1367.51","138","794.37","1392.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","1059.75","59.3","","720.78","230.14","2010.94","427","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1059.75","59.3","","344.45","344.45","344.45","1 through 10","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1401.98","78.45","","1120.13","1120.13","1120.13","1 through 10","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1401.98","78.45","","456.17","105.33","1284.66","242","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","AETNA [1001]","HB CH AETNA HMO / PPO","1156.42","58.3","","464.71","67.87","1012.10","221","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.42","58.3","","293.04","293.04","293.04","11","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.29","53","","983.89","983.89","983.89","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1150.47","58","","677.18","677.18","677.18","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1239.73","62.5","","46.58","46.58","46.58","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.01","73","","747.15","747.15","747.15","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","881.70","44.45","","1141.67","481.21","1141.67","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","881.70","44.45","","76.54","76.54","76.54","1 through 10","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","WELLPOINT [1015]","HB CH WELLPOINT","1545.40","77.91","","273.64","94.28","1367.51","138","881.7","1545.4","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.26","59.3","","720.78","230.14","2010.94","427","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1176.26","59.3","","344.45","344.45","344.45","1 through 10","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1556.11","78.45","","1120.13","1120.13","1120.13","1 through 10","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.11","78.45","","456.17","105.33","1284.66","242","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","AETNA [1001]","HB CH AETNA HMO / PPO","1271.61","58.3","","464.71","67.87","1012.10","221","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1271.61","58.3","","293.04","293.04","293.04","11","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1156.01","53","","983.89","983.89","983.89","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1265.07","58","","677.18","677.18","677.18","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1363.22","62.5","","46.58","46.58","46.58","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1592.24","73","","747.15","747.15","747.15","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","969.52","44.45","","1141.67","481.21","1141.67","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","969.52","44.45","","76.54","76.54","76.54","1 through 10","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","WELLPOINT [1015]","HB CH WELLPOINT","1699.33","77.91","","273.64","94.28","1367.51","138","969.52","1699.33","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","1293.42","59.3","","720.78","230.14","2010.94","427","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1293.42","59.3","","344.45","344.45","344.45","1 through 10","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1711.11","78.45","","1120.13","1120.13","1120.13","1 through 10","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1711.11","78.45","","456.17","105.33","1284.66","242","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","AETNA [1001]","HB CH AETNA HMO / PPO","2482.46","58.3","","464.71","67.87","1012.10","221","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2482.46","58.3","","293.04","293.04","293.04","11","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2256.78","53","","983.89","983.89","983.89","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2469.69","58","","677.18","677.18","677.18","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2661.30","62.5","","46.58","46.58","46.58","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3108.40","73","","747.15","747.15","747.15","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1892.72","44.45","","1141.67","481.21","1141.67","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1892.72","44.45","","76.54","76.54","76.54","1 through 10","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","both","","","4258.08","3193.56","WELLPOINT [1015]","HB CH WELLPOINT","3317.47","77.91","","273.64","94.28","1367.51","138","1892.72","3317.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4258.08","3193.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2525.04","59.3","","720.78","230.14","2010.94","427","2129.04","3340.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4258.08","3193.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2525.04","59.3","","344.45","344.45","344.45","1 through 10","2129.04","3340.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4258.08","3193.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3340.46","78.45","","1120.13","1120.13","1120.13","1 through 10","2129.04","3340.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X109MM 3 HOLE TITANIUM LCP PERIARTIC PROXIMAL PL RIGHT","SUP-ITM-10096133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4258.08","3193.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3340.46","78.45","","456.17","105.33","1284.66","242","2129.04","3340.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","AETNA [1001]","HB CH AETNA HMO / PPO","1412.68","58.3","","464.71","67.87","1012.10","221","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1412.68","58.3","","293.04","293.04","293.04","11","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1284.26","53","","983.89","983.89","983.89","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1405.42","58","","677.18","677.18","677.18","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1514.46","62.5","","46.58","46.58","46.58","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1768.88","73","","747.15","747.15","747.15","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1077.08","44.45","","1141.67","481.21","1141.67","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1077.08","44.45","","76.54","76.54","76.54","1 through 10","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","both","","","2423.13","1817.35","WELLPOINT [1015]","HB CH WELLPOINT","1887.86","77.91","","273.64","94.28","1367.51","138","1077.08","1887.86","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2423.13","1817.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","1436.92","59.3","","720.78","230.14","2010.94","427","1211.57","1900.95","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2423.13","1817.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1436.92","59.3","","344.45","344.45","344.45","1 through 10","1211.57","1900.95","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2423.13","1817.35","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1900.95","78.45","","1120.13","1120.13","1120.13","1 through 10","1211.57","1900.95","percent of total billed charges",""
"HUMERUS PLATE 3.5X117MM 7 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10013255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2423.13","1817.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1900.95","78.45","","456.17","105.33","1284.66","242","1211.57","1900.95","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","AETNA [1001]","HB CH AETNA HMO / PPO","2392.21","58.3","","464.71","67.87","1012.10","221","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2392.21","58.3","","293.04","293.04","293.04","11","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2174.74","53","","983.89","983.89","983.89","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2379.90","58","","677.18","677.18","677.18","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2564.55","62.5","","46.58","46.58","46.58","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2995.39","73","","747.15","747.15","747.15","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.91","44.45","","1141.67","481.21","1141.67","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.91","44.45","","76.54","76.54","76.54","1 through 10","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","WELLPOINT [1015]","HB CH WELLPOINT","3196.87","77.91","","273.64","94.28","1367.51","138","1823.91","3196.87","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","2433.25","59.3","","720.78","230.14","2010.94","427","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2433.25","59.3","","344.45","344.45","344.45","1 through 10","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3219.02","78.45","","1120.13","1120.13","1120.13","1 through 10","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3219.02","78.45","","456.17","105.33","1284.66","242","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","AETNA [1001]","HB CH AETNA HMO / PPO","2027.58","58.3","","464.71","67.87","1012.10","221","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2027.58","58.3","","293.04","293.04","293.04","11","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1843.26","53","","983.89","983.89","983.89","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2017.15","58","","677.18","677.18","677.18","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2173.65","62.5","","46.58","46.58","46.58","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2538.82","73","","747.15","747.15","747.15","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.90","44.45","","1141.67","481.21","1141.67","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.90","44.45","","76.54","76.54","76.54","1 through 10","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","WELLPOINT [1015]","HB CH WELLPOINT","2709.59","77.91","","273.64","94.28","1367.51","138","1545.9","2709.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","2062.36","59.3","","720.78","230.14","2010.94","427","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2062.36","59.3","","344.45","344.45","344.45","1 through 10","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2728.37","78.45","","1120.13","1120.13","1120.13","1 through 10","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2728.37","78.45","","456.17","105.33","1284.66","242","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","AETNA [1001]","HB CH AETNA HMO / PPO","2152.42","58.3","","464.71","67.87","1012.10","221","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2152.42","58.3","","293.04","293.04","293.04","11","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1956.75","53","","983.89","983.89","983.89","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2141.35","58","","677.18","677.18","677.18","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2307.49","62.5","","46.58","46.58","46.58","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2695.15","73","","747.15","747.15","747.15","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.09","44.45","","1141.67","481.21","1141.67","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.09","44.45","","76.54","76.54","76.54","1 through 10","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","WELLPOINT [1015]","HB CH WELLPOINT","2876.42","77.91","","273.64","94.28","1367.51","138","1641.09","2876.42","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2189.34","59.3","","720.78","230.14","2010.94","427","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2189.34","59.3","","344.45","344.45","344.45","1 through 10","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2896.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2896.36","78.45","","456.17","105.33","1284.66","242","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","AETNA [1001]","HB CH AETNA HMO / PPO","2004.75","58.3","","464.71","67.87","1012.10","221","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2004.75","58.3","","293.04","293.04","293.04","11","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1822.50","53","","983.89","983.89","983.89","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1994.43","58","","677.18","677.18","677.18","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2149.18","62.5","","46.58","46.58","46.58","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2510.24","73","","747.15","747.15","747.15","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.49","44.45","","1141.67","481.21","1141.67","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.49","44.45","","76.54","76.54","76.54","1 through 10","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","WELLPOINT [1015]","HB CH WELLPOINT","2679.08","77.91","","273.64","94.28","1367.51","138","1528.49","2679.08","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","2039.14","59.3","","720.78","230.14","2010.94","427","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2039.14","59.3","","344.45","344.45","344.45","1 through 10","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2697.64","78.45","","1120.13","1120.13","1120.13","1 through 10","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2697.64","78.45","","456.17","105.33","1284.66","242","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","AETNA [1001]","HB CH AETNA HMO / PPO","1898.35","58.3","","464.71","67.87","1012.10","221","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1898.35","58.3","","293.04","293.04","293.04","11","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.78","53","","983.89","983.89","983.89","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1888.58","58","","677.18","677.18","677.18","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2035.11","62.5","","46.58","46.58","46.58","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2377.01","73","","747.15","747.15","747.15","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1447.37","44.45","","1141.67","481.21","1141.67","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1447.37","44.45","","76.54","76.54","76.54","1 through 10","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","WELLPOINT [1015]","HB CH WELLPOINT","2536.89","77.91","","273.64","94.28","1367.51","138","1447.37","2536.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.91","59.3","","720.78","230.14","2010.94","427","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1930.91","59.3","","344.45","344.45","344.45","1 through 10","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2554.47","78.45","","1120.13","1120.13","1120.13","1 through 10","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2554.47","78.45","","456.17","105.33","1284.66","242","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","AETNA [1001]","HB CH AETNA HMO / PPO","1195.25","58.3","","464.71","67.87","1012.10","221","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1195.25","58.3","","293.04","293.04","293.04","11","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.59","53","","983.89","983.89","983.89","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1189.10","58","","677.18","677.18","677.18","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1281.36","62.5","","46.58","46.58","46.58","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1496.62","73","","747.15","747.15","747.15","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.30","44.45","","1141.67","481.21","1141.67","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.30","44.45","","76.54","76.54","76.54","1 through 10","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","WELLPOINT [1015]","HB CH WELLPOINT","1597.29","77.91","","273.64","94.28","1367.51","138","911.3","1597.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","1215.75","59.3","","720.78","230.14","2010.94","427","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1215.75","59.3","","344.45","344.45","344.45","1 through 10","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1608.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1608.36","78.45","","456.17","105.33","1284.66","242","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","AETNA [1001]","HB CH AETNA HMO / PPO","2138.99","58.3","","464.71","67.87","1012.10","221","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2138.99","58.3","","293.04","293.04","293.04","11","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1944.54","53","","983.89","983.89","983.89","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2127.99","58","","677.18","677.18","677.18","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2293.09","62.5","","46.58","46.58","46.58","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2678.33","73","","747.15","747.15","747.15","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.84","44.45","","1141.67","481.21","1141.67","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.84","44.45","","76.54","76.54","76.54","1 through 10","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","WELLPOINT [1015]","HB CH WELLPOINT","2858.47","77.91","","273.64","94.28","1367.51","138","1630.84","2858.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2175.68","59.3","","720.78","230.14","2010.94","427","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2175.68","59.3","","344.45","344.45","344.45","1 through 10","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2878.28","78.45","","1120.13","1120.13","1120.13","1 through 10","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2878.28","78.45","","456.17","105.33","1284.66","242","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","AETNA [1001]","HB CH AETNA HMO / PPO","1303.32","58.3","","464.71","67.87","1012.10","221","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1303.32","58.3","","293.04","293.04","293.04","11","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1184.84","53","","983.89","983.89","983.89","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1296.61","58","","677.18","677.18","677.18","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1397.21","62.5","","46.58","46.58","46.58","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1631.94","73","","747.15","747.15","747.15","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.70","44.45","","1141.67","481.21","1141.67","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.70","44.45","","76.54","76.54","76.54","1 through 10","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","WELLPOINT [1015]","HB CH WELLPOINT","1741.71","77.91","","273.64","94.28","1367.51","138","993.7","1741.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1325.68","59.3","","720.78","230.14","2010.94","427","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1325.68","59.3","","344.45","344.45","344.45","1 through 10","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1753.78","78.45","","1120.13","1120.13","1120.13","1 through 10","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1753.78","78.45","","456.17","105.33","1284.66","242","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","464.71","67.87","1012.10","221","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","293.04","293.04","293.04","11","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","983.89","983.89","983.89","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2196.61","58","","677.18","677.18","677.18","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2367.03","62.5","","46.58","46.58","46.58","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","747.15","747.15","747.15","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","1141.67","481.21","1141.67","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","76.54","76.54","76.54","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","273.64","94.28","1367.51","138","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","720.78","230.14","2010.94","427","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2245.84","59.3","","344.45","344.45","344.45","1 through 10","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","456.17","105.33","1284.66","242","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","AETNA [1001]","HB CH AETNA HMO / PPO","2947.29","58.3","","464.71","67.87","1012.10","221","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2947.29","58.3","","293.04","293.04","293.04","11","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2679.35","53","","983.89","983.89","983.89","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2932.12","58","","677.18","677.18","677.18","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3159.61","62.5","","46.58","46.58","46.58","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3690.43","73","","747.15","747.15","747.15","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2247.12","44.45","","1141.67","481.21","1141.67","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2247.12","44.45","","76.54","76.54","76.54","1 through 10","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.38","3791.53","WELLPOINT [1015]","HB CH WELLPOINT","3938.65","77.91","","273.64","94.28","1367.51","138","2247.12","3938.65","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.38","3791.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","2997.84","59.3","","720.78","230.14","2010.94","427","2527.69","3965.95","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.38","3791.53","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2997.84","59.3","","344.45","344.45","344.45","1 through 10","2527.69","3965.95","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.38","3791.53","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3965.95","78.45","","1120.13","1120.13","1120.13","1 through 10","2527.69","3965.95","percent of total billed charges",""
"HUMERUS PLATE 86MM 1 HOLE BONE HUMERAL ARM AXSOS TITANIUM LOCKING PROXIMALIMAL LATERAL LEFT","SUP-ITM-10034221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.38","3791.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3965.95","78.45","","456.17","105.33","1284.66","242","2527.69","3965.95","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","AETNA [1001]","HB CH AETNA HMO / PPO","3142.02","58.3","","464.71","67.87","1012.10","221","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3142.02","58.3","","293.04","293.04","293.04","11","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2856.38","53","","983.89","983.89","983.89","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3125.85","58","","677.18","677.18","677.18","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3368.38","62.5","","46.58","46.58","46.58","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3934.26","73","","747.15","747.15","747.15","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2395.59","44.45","","1141.67","481.21","1141.67","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2395.59","44.45","","76.54","76.54","76.54","1 through 10","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.40","4042.05","WELLPOINT [1015]","HB CH WELLPOINT","4198.88","77.91","","273.64","94.28","1367.51","138","2395.59","4198.88","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.40","4042.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","3195.91","59.3","","720.78","230.14","2010.94","427","2694.7","4227.98","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.40","4042.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3195.91","59.3","","344.45","344.45","344.45","1 through 10","2694.7","4227.98","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.40","4042.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4227.98","78.45","","1120.13","1120.13","1120.13","1 through 10","2694.7","4227.98","percent of total billed charges",""
"HUMERUS PLATE 86MM 3 HOLE BONE HUMERAL PROXIMAL LATERAL LEFT","SUP-ITM-10186950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.40","4042.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4227.98","78.45","","456.17","105.33","1284.66","242","2694.7","4227.98","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","464.71","67.87","1012.10","221","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","293.04","293.04","293.04","11","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","983.89","983.89","983.89","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.75","58","","677.18","677.18","677.18","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.94","62.5","","46.58","46.58","46.58","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","747.15","747.15","747.15","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","1141.67","481.21","1141.67","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","76.54","76.54","76.54","1 through 10","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","273.64","94.28","1367.51","138","1661.32","2911.89","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","720.78","230.14","2010.94","427","1868.75","2932.07","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.34","59.3","","344.45","344.45","344.45","1 through 10","1868.75","2932.07","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.75","2932.07","percent of total billed charges",""
"HUMERUS PLATE 90MM 3 HOLE SHAFT BONE HUMERAL SUTURE TITANIUM","SUP-ITM-10115027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","456.17","105.33","1284.66","242","1868.75","2932.07","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","464.71","67.87","1012.10","221","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","293.04","293.04","293.04","11","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","983.89","983.89","983.89","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2196.61","58","","677.18","677.18","677.18","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2367.03","62.5","","46.58","46.58","46.58","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","747.15","747.15","747.15","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","1141.67","481.21","1141.67","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","76.54","76.54","76.54","1 through 10","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","273.64","94.28","1367.51","138","1683.43","2950.65","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","720.78","230.14","2010.94","427","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2245.84","59.3","","344.45","344.45","344.45","1 through 10","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","456.17","105.33","1284.66","242","1893.63","2971.1","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","AETNA [1001]","HB CH AETNA HMO / PPO","567.78","58.3","","1530.90","1160.93","1884.08","89","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.16","53","","5253.92","5253.92","5253.92","1 through 10","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","564.86","58","","12181.47","12181.47","12181.47","1 through 10","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","608.68","62.5","","1350.68","1350.68","1350.68","1 through 10","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","432.89","44.45","","1910.74","891.94","1910.74","1 through 10","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","WELLPOINT [1015]","HB CH WELLPOINT","758.76","77.91","","1829.79","1561.50","2617.12","88","432.89","758.76","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","973.89","730.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","577.52","59.3","","1359.46","1201.30","1689.00","61","486.95","764.02","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","973.89","730.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","577.52","59.3","","1718.92","1718.92","1718.92","1 through 10","486.95","764.02","percent of total billed charges",""
"HUMERUS SPACER 36X6MM SHOULDER TITANIUM","SUP-ITM-10135907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","973.89","730.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.02","78.45","","1910.74","1019.06","2344.84","74","486.95","764.02","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","AETNA [1001]","HB CH AETNA HMO / PPO","5915.12","58.3","","1530.90","1160.93","1884.08","89","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5377.38","53","","5253.92","5253.92","5253.92","1 through 10","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5884.68","58","","12181.47","12181.47","12181.47","1 through 10","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6341.25","62.5","","1350.68","1350.68","1350.68","1 through 10","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4509.90","44.45","","1910.74","891.94","1910.74","1 through 10","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","both","","","10146.00","7609.50","WELLPOINT [1015]","HB CH WELLPOINT","7904.75","77.91","","1829.79","1561.50","2617.12","88","4509.9","7904.75","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10146.00","7609.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","6016.58","59.3","","1359.46","1201.30","1689.00","61","5073","7959.54","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10146.00","7609.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","6016.58","59.3","","1718.92","1718.92","1718.92","1 through 10","5073","7959.54","percent of total billed charges",""
"HUMERUS STEM 6MMX80 PROSTHESIS HUMERAL RECONSTRUCTION DISTAL","SUP-ITM-10197161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10146.00","7609.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7959.54","78.45","","1910.74","1019.06","2344.84","74","5073","7959.54","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1530.90","1160.93","1884.08","89","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","5253.92","5253.92","5253.92","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3132.00","58","","12181.47","12181.47","12181.47","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3375.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2400.30","44.45","","1910.74","891.94","1910.74","1 through 10","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","1829.79","1561.50","2617.12","88","2400.3","4207.14","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1359.46","1201.30","1689.00","61","2700","4236.3","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2700","4236.3","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","1910.74","1019.06","2344.84","74","2700","4236.3","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.64","101.65","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","13.29","83.94","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","224.00","168.00","AETNA [1001]","HB CH AETNA HMO / PPO","130.59","58.3","","123.61","123.61","123.61","17","26.63","212.8","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","224.00","168.00","TRICARE [160005]","HB NWH TRICARE","212.80","95","","31.10","31.10","31.10","1 through 10","26.63","212.8","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","127.75","127.75","1 through 10","28.01","175.73","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","167.60","436.00","13","28.01","175.73","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","167.60","167.60","167.60","1 through 10","28.01","175.73","percent of total billed charges",""
"Hymenectomy Part or Revision","PX-76001337","CDM","56700","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1984.13","3603.34","per diem",""
"Hymenectomy Part or Revision","PX-76001337","CDM","56700","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2317.13","50.1","","3823.55","1952.28","3904.56","1 through 10","1850","3628.31","percent of total billed charges",""
"Hymenectomy Part or Revision","PX-76001337","CDM","56700","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","8692.73","3498.42","8692.73","1 through 10","1850","3628.31","percent of total billed charges",""
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","32739.07","24554.30","MEDICARE [2001]","HB NWH MEDICARE","11336.18","","Case rate ($11,336.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,591.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,733.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,729.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,548.30. The transfer operating threshold is the transfer adjustment factor * $10,591.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.89. The transfer capital threshold is the transfer adjustment factor * $787.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11232.66","11212.36","11232.66","1 through 10","10103.87","11617.5972","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6738.39","","Case rate ($6,542.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,042.19. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6736.68","6736.68","6736.68","1 through 10","6411.29","7751.1","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7193.24","","Case rate ($7,193.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,693.29. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7062.84","7062.84","7062.84","1 through 10","6411.29","7751.1","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","MEDICARE [2001]","HB NWH MEDICARE","7193.24","","Case rate ($7,193.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,693.29. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7177.68","1197.48","7177.68","26","6411.29","7751.1","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6411.29","","Case rate ($6,542.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,042.19. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6398.82","6398.82","6398.91","1 through 10","6411.29","7751.1","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6411.29","","Case rate ($6,542.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,042.19. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7457.15","7457.15","7457.15","1 through 10","6411.29","7751.1","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","20971.54","15728.65","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6411.29","","Case rate ($6,542.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,720.55, add-ons for qualifying new technology services are included. If operating cost exceeds $51,862.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,042.19. The transfer operating threshold is the transfer adjustment factor * $6,720.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.94. The transfer capital threshold is the transfer adjustment factor * $499.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6432.45","6432.45","6432.45","1 through 10","6411.29","7751.1","other","Inpatient DRG"
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","33012.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21786.12","","Standard inlier is a Case rate ($21,786.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,453, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,092.45) for the length of stay and the standard reimbursement.","21786.11","21786.11","21786.11","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","33012.80","","MASSHEALTH [3001]","HB NWH MEDICAID","9446.22","","Case rate ($10,176.82). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,606.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10202.99","10202.99","10202.99","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MINOR","199","DRG","","","","","","","","inpatient","","","24624.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12049.12","","Standard inlier is a Case rate ($12,049.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,008, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,710.42) for the length of stay and the standard reimbursement.","12049.12","12049.12","12049.12","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MINOR","199","DRG","","","","","","","","inpatient","","","24624.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12943.16","","Standard inlier is a Case rate ($12,943.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,008, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,837.23) for the length of stay and the standard reimbursement.","12943.16","12943.16","12943.16","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","23077.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15816.20","","Standard inlier is a Case rate ($15,816.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,752, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,245.04) for the length of stay and the standard reimbursement.","15816.20","15816.20","15816.20","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","23077.42","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8367.8844","","Fee schedule rate ($10,877.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8367.8844","10457.96","10457.96","1 through 10","3740.11","78904.29","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","23077.42","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5241.18","","Case rate ($5,646.54). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,076.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5877.62","5877.62","5877.62","1 through 10","3740.11","78904.29","case rate",""
"Hypovolemia And Related Electrolyte Disorders,EXTREME","422","DRG","","","","","","","","inpatient","","","24131.85","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","6925.6848","","Fee schedule rate ($49,890.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6925.6848","49890.72","49890.72","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,EXTREME","422","DRG","","","","","","","","inpatient","","","24131.85","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","35448.02","","Fee schedule rate ($35,448.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35448.02","35448.02","35448.02","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17466.94","","Standard inlier is a Case rate ($17,466.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,479.50) for the length of stay and the standard reimbursement.","16673.21","16673.21","16673.21","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18762.98","","Standard inlier is a Case rate ($18,762.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,663.33) for the length of stay and the standard reimbursement.","18762.97","18762.97","18762.97","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","6925.6848","","Fee schedule rate ($49,890.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6925.6848","19364.16","19364.16","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","MASSHEALTH [3001]","HB NWH MEDICAID","7941.73","","Case rate ($8,555.96). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,985.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2457.87","2457.87","2457.87","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","7941.73","","Case rate ($8,555.96). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,985.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","19021.88","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","7941.73","","Case rate ($8,555.96). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,985.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8577.96","8577.96","8577.96","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MINOR","422","DRG","","","","","","","","inpatient","","","12514.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8062.98","","Standard inlier is a Case rate ($8,062.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $19,919, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,144.57) for the length of stay and the standard reimbursement.","7696.58","7696.58","7696.58","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MINOR","422","DRG","","","","","","","","inpatient","","","12514.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8661.25","","Standard inlier is a Case rate ($8,661.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $19,919, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,229.43) for the length of stay and the standard reimbursement.","8267.55","8267.55","8267.55","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MINOR","422","DRG","","","","","","","","inpatient","","","12514.95","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","7271.9336","","Fee schedule rate ($7,271.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7271.9336","7271.92","7271.92","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MINOR","422","DRG","","","","","","","","inpatient","","","12514.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9416.46","","Fee schedule rate ($9,416.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9416.46","9416.46","9416.46","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","10856.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12000.09","","Standard inlier is a Case rate ($12,000.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,703.46) for the length of stay and the standard reimbursement.","12000.09","12000.09","12000.09","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","10856.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12890.49","","Standard inlier is a Case rate ($12,890.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,829.75) for the length of stay and the standard reimbursement.","12304.56","12304.56","12304.56","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","10856.00","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","6925.6848","","Fee schedule rate ($10,349.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6925.6848","10349.44","10349.44","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","10856.00","","MASSHEALTH [3001]","HB NWH MEDICAID","4641.43","","Case rate ($5,000.41). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,430.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5205.05","5205.05","5205.05","1 through 10","3755.21","82318.93","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","10856.00","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","4641.43","","Case rate ($5,000.41). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,430.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6266.59","6266.59","6266.59","1 through 10","3755.21","82318.93","case rate",""
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","both","","","9474.00","7105.50","AETNA [1001]","HB CH AETNA HMO / PPO","5523.34","58.3","","1586.81","1586.81","1586.81","1 through 10","3713.25","8083.96","percent of total billed charges",""
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6671.42","3406.49","6812.97","1 through 10","3713.25","7939.38","other","ASC "
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6680.86","3411.20","6822.40","1 through 10","3713.25","7939.38","other","ASC "
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8726.14","8726.14","8726.14","1 through 10","3713.25","7939.38","other","Multiple Surgery"
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","8837.54","8837.54","8837.54","1 through 10","3713.25","7939.38","other","Multiple Surgery"
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7432.35","78.45","","6356.44","6356.44","6356.44","1 through 10","3713.25","7939.38","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","AETNA [1001]","HB CH AETNA HMO / PPO","3457.19","58.3","","3384.99","2343.98","4687.96","33","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3892.38","3512.03","3894.28","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3357.59","3715.47","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6247.91","3123.96","6450.00","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","3394.33","11008.22","13","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","68","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1788.00","1788.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","5631.00","28","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3707.76","3703.36","11124.48","12","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3708.27","3700.36","3708.27","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","69","2125.14","4652.09","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","141","2125.14","4652.09","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3516.49","59.3","","3498.42","2422.52","9890.51","28","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","14982.24","75","2125.14","4652.09","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5249.10","5249.10","26245.50","27","2125.14","4652.09","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2635.89","44.45","","2788.73","2719.93","3766.90","1 through 10","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4652.09","78.45","","4589.74","2294.87","6517.12","24","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2635.89","44.45","","9361.68","9361.68","9361.68","1 through 10","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","AETNA [1001]","HB CH AETNA HMO / PPO","2420.62","58.3","","2288.98","2288.98","2288.98","1 through 10","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6247.91","6247.91","6247.91","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","4359.58","3909.61","5217.21","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","MEDICARE [2001]","HB NWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","5106.00","1702.00","5106.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1685.00","1685.00","1685.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","4152.00","3114.00","TRICARE [160005]","HB NWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","7551.76","3587.09","7551.76","1 through 10","2125.14","4626.56","other","Tricare OPPS"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","19","1845.56","3257.24","other","ASC "
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","33","1845.56","3257.24","other","ASC "
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2462.14","59.3","","2365.68","2365.68","2365.68","1 through 10","1845.56","3257.24","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","14982.24","18","1845.56","3257.24","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5249.10","5249.10","5249.10","1 through 10","1845.56","3257.24","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1845.56","44.45","","6356.44","6356.44","6356.44","1 through 10","1845.56","3257.24","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3257.24","78.45","","3103.65","780.00","3103.65","1 through 10","1845.56","3257.24","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","both","","","6632.00","4974.00","AETNA [1001]","HB CH AETNA HMO / PPO","3866.46","58.3","","5990.92","4687.96","5990.92","1 through 10","2845.13","5166.99","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","both","","","6632.00","4974.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2845.13","5166.99","per diem",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3254.32","49.07","","6812.97","6671.42","6812.97","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3322.63","50.1","","6822.40","6822.40","6822.40","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3932.78","59.3","","6191.68","6191.68","6191.68","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5202.80","78.45","","4589.74","4589.74","4589.74","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","AETNA [1001]","HB CH AETNA HMO / PPO","4660.50","58.3","","4949.91","4298.43","6142.31","1 through 10","3713.25","8083.96","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","9617.32","6482.39","9617.32","1 through 10","3713.25","8083.96","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MEDICARE [2001]","HB NWH MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5862.33","5862.33","5862.33","1 through 10","3713.25","8083.96","other","OPPS APC"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1652.00","1652.00","1652.00","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1788.00","1788.00","1788.00","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","938.50","1877.00","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","5744.50","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5768.53","5768.53","5768.53","1 through 10","3713.25","8083.96","other","OPPS APC"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6812.97","6671.42","6812.97","16","3553.33","7939.38","other","ASC "
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6822.40","6680.86","6822.40","22","3553.33","7939.38","other","ASC "
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4740.44","59.3","","8868.28","4845.05","10231.56","12","3553.33","7939.38","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8726.14","4363.07","8726.14","1 through 10","3553.33","7939.38","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","17675.08","4585.87","27515.19","1 through 10","3553.33","7939.38","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6271.29","78.45","","4589.74","3178.22","9889.84","1 through 10","3553.33","7939.38","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","AETNA [1001]","HB CH AETNA HMO / PPO","3017.61","58.3","","2853.71","2755.70","2853.71","1 through 10","2743.28","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5768.53","5768.53","5768.53","1 through 10","2743.28","8083.96","other","OPPS APC"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","10916.96","10916.66","10916.96","1 through 10","2743.28","8083.96","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","MEDICARE [2001]","HB NWH MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5862.33","5862.33","5862.33","1 through 10","2743.28","8083.96","other","OPPS APC"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","1 through 10","2743.28","8083.96","per diem",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","5176.00","3882.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","11","2743.28","8083.96","per diem",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6812.97","6671.42","6812.97","14","2300.73","4718.12","other","ASC "
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6822.40","6680.86","6822.40","33","2300.73","4718.12","other","ASC "
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3069.37","59.3","","2949.34","2949.34","9053.71","17","2300.73","4718.12","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8726.14","8726.14","8726.14","1 through 10","2300.73","4718.12","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","9171.73","9171.73","9171.73","1 through 10","2300.73","4718.12","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4060.57","78.45","","3869.37","3869.37","4589.74","1 through 10","2300.73","4718.12","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","4336.00","3252.00","AETNA [1001]","HB CH AETNA HMO / PPO","2527.89","58.3","","3384.99","2390.47","3384.99","1 through 10","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","4336.00","3252.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","4336.00","3252.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","4336.00","3252.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3818.15","3818.15","3899.16","1 through 10","1927.35","7178","other","ASC "
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","1927.35","7178","other","ASC "
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2571.25","59.3","","1166.14","1166.14","1166.14","1 through 10","1927.35","7178","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","2497.04","4994.08","1 through 10","1927.35","7178","other","Multiple Surgery"
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","10115.66","5249.10","10115.66","1 through 10","1927.35","7178","other","Multiple Surgery"
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3401.59","78.45","","3766.90","3766.90","3766.90","1 through 10","1927.35","7178","percent of total billed charges",""
"I&D Abscess Ischiorectal/Perirectal","PX-75000211","CDM","46040","CPT","0750","RC","","","","outpatient","","","3390.00","2542.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1698.39","50.1","","1586.56","1586.56","1586.56","1 through 10","1356","2659.46","percent of total billed charges",""
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5409.00","4056.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1963.63","1963.63","1963.63","1 through 10","2140.46","4472.66","other","ASC "
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1592.00","1194.00","MEDICARE [2001]","HB NWH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","682.97","1240.33","other","OPPS APC"
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","both","","","877.00","657.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","146.67","683.27","per diem",""
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","340.87","340.87","340.87","1 through 10","206.14","1873.9","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","439.36","439.36","439.36","1 through 10","176.45","349.82","other","Multiple Surgery"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","MEDICARE [2001]","HB NWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","707.91","117.98","707.91","1 through 10","176.45","349.82","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","285.32","285.32","291.37","1 through 10","176.45","567.68","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","291.77","285.72","291.77","1 through 10","176.45","567.68","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.26","59.3","","4845.05","4845.05","4845.05","1 through 10","176.45","567.68","percent of total billed charges",""
"I&D Abscess Vulva/Perineal","PX-76001330","CDM","56405","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","225.72","225.72","442.06","1 through 10","273","1873.9","other","ASC "
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2840.00","2130.00","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","2212.64","other","OPPS APC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2840.00","2130.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","236.00","243.00","1 through 10","1237.95","2212.64","per diem",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2271.35","2271.35","2271.35","1 through 10","1237.95","2227.98","other","ASC "
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2227.31","2274.50","1 through 10","1237.95","2227.98","other","ASC "
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1237.95","2227.98","other","Multiple Surgery"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2227.98","78.45","","3766.90","3766.90","3766.90","1 through 10","1237.95","2227.98","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","194.26","194.26","194.26","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","515.10","19","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","530.04","27","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","185.47","185.47","354.83","14","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","178.44","178.44","178.44","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","194.26","194.26","194.26","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","515.10","17","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","530.04","24","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","185.47","185.47","354.83","13","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Dna/Rna Zika Virus Amplified Probe Tq","PX-30003476","CDM","87662","CPT","0306","RC","","","","outpatient","","","520.00","390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","407.94","78.45","","389.01","389.01","389.01","1 through 10","156.27","407.94","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","194.26","194.26","194.26","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","171.70","14","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","176.68","11","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","185.47","185.47","194.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","133.49","133.49","133.49","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","178.44","178.44","178.44","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna H Pylori Clarithromycin Resist Amp Prb Tq","PX-30003843","CDM","87513","CPT","0306","RC","","","","outpatient","","","928.00","696.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","455.37","49.07","","455.33","455.33","455.33","1 through 10","371.2","728.02","percent of total billed charges",""
"Iadna H Pylori Clarithromycin Resist Amp Prb Tq","PX-30003843","CDM","87513","CPT","0306","RC","","","","outpatient","","","928.00","696.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","464.93","50.1","","464.90","464.89","464.90","1 through 10","371.2","728.02","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","AETNA [1001]","HB CH AETNA HMO / PPO","176.65","58.3","","167.27","167.27","167.27","641","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","221.19","73","","215.35","215.35","215.35","1 through 10","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","160.59","53","","156.35","156.35","156.35","1 through 10","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","221.19","73","","52.61","47.53","168.74","1 through 10","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","TRICARE [160005]","HB NWH TRICARE","287.85","95","","42.28","40.17","337.28","12","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","287.85","95","","35.09","35.09","35.09","1 through 10","34.39","287.85","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","179.68","59.3","","518.61","172.87","518.61","1023","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","179.68","59.3","","172.87","172.87","172.87","1 through 10","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.68","44.45","","134.40","134.40","226.80","28","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","237.70","78.45","","226.80","134.40","226.80","566","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.68","44.45","","134.40","134.40","134.40","1 through 10","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus Types 16 & 18 Only","PX-30002926","CDM","87625","CPT","0306","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB CH AETNA HMO / PPO","123.60","58.3","","116.80","112.80","116.80","1 through 10","39.74","215.32","percent of total billed charges",""
"Iadna Human Papillomavirus Types 16 & 18 Only","PX-30002926","CDM","87625","CPT","0306","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.72","59.3","","120.72","120.72","120.72","1 through 10","94.23","166.31","percent of total billed charges",""
"Iadna Human Papillomavirus Types 16 & 18 Only","PX-30002926","CDM","87625","CPT","0306","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","166.31","78.45","","158.37","158.37","158.37","1 through 10","94.23","166.31","percent of total billed charges",""
"Iadna Orthopoxvirus Amplified Probe Technique Ea","PX-30003797","CDM","87593","CPT","0306","RC","","","","outpatient","","","293.00","219.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.75","59.3","","167.01","167.01","167.01","1 through 10","117.2","229.86","percent of total billed charges",""
"Iadna Orthopoxvirus Amplified Probe Technique Ea","PX-30003825","CDM","87593","CPT","0306","RC","","","","outpatient","","","293.00","219.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.75","59.3","","167.01","167.01","167.01","1 through 10","117.2","229.86","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","800.00","600.00","AETNA [1001]","HB CH AETNA HMO / PPO","466.40","58.3","","441.13","441.13","441.13","1 through 10","103.06","841","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","800.00","600.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","474.40","59.3","","455.91","455.91","455.91","1 through 10","78.13","627.6","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","800.00","600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","627.60","78.45","","598.13","598.12","598.13","1 through 10","78.13","627.6","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","51.36","0.57","85.05","29","50.28","272.51","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","68.34","68.34","68.34","1 through 10","50.28","272.51","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","87.90","87.90","131.89","19","54.9","173.46","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","115.32","115.32","115.32","16","54.9","173.46","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","150.02","150.02","150.02","1 through 10","64.35","116.87","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","75.01","75.01","75.01","1 through 10","64.35","116.87","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","147.44","84.42","156.90","20","54.9","117.68","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","both","","","25.00","18.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","14.50","58","","50.00","50.00","50.00","1 through 10","10.73","19.48","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","both","","","25.00","18.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","15.63","62.5","","25.00","25.00","25.00","1 through 10","10.73","19.48","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","outpatient","","","25.00","18.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","14.83","59.3","","25.66","15.24","38.53","20","9.15","25.01","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","AETNA [1001]","HB CH AETNA HMO / PPO","278.67","58.3","","271.03","271.03","271.03","1 through 10","103.06","757.42","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","both","","","358.00","268.50","AETNA [1001]","HB CH AETNA HMO / PPO","208.71","58.3","","202.99","202.99","202.99","18","103.06","757.42","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","268.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.29","59.3","","209.79","209.79","244.47","1 through 10","131.03","482.12","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","268.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","280.85","78.45","","275.23","275.23","275.23","1 through 10","131.03","482.12","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB CH AETNA HMO / PPO","130.01","58.3","","123.04","123.04","123.04","99","34.39","211.85","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","TRICARE [160005]","HB NWH TRICARE","211.85","95","","42.28","42.28","42.28","1 through 10","34.39","211.85","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","211.85","95","","35.09","35.09","35.09","1 through 10","34.39","211.85","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.12","44.45","","166.83","98.87","166.83","1 through 10","34.39","211.85","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","WELLPOINT [1015]","HB CH WELLPOINT","173.74","77.91","","170.91","170.91","170.91","35","34.39","211.85","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","127.16","97","26.86","174.94","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","127.16","1 through 10","26.86","174.94","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.94","78.45","","166.83","98.87","166.83","83","26.86","174.94","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","2591.00","1943.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.54","42.9","","1342.20","1342.20","1342.20","1 through 10","257.73","2461.45","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","128.17","96.13","AETNA [1001]","HB CH AETNA HMO / PPO","74.72","58.3","","71.10","36.66","71.10","1 through 10","56.97","279.69","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","128.17","96.13","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","100.55","78.45","","157.81","157.81","157.81","1 through 10","64.09","190.63","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","AETNA [1001]","HB CH AETNA HMO / PPO","17.65","58.3","","17.17","17.17","17.17","28","13.46","74.87","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","TRICARE [160005]","HB NWH TRICARE","28.77","95","","22.35","22.35","22.35","1 through 10","13.46","74.87","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.46","44.45","","27.91","23.81","27.91","1 through 10","13.46","74.87","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","WELLPOINT [1015]","HB CH WELLPOINT","23.59","77.91","","30.28","30.28","31.40","1 through 10","13.46","74.87","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","30.28","22.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","15.81","52.2","","15.59","15.59","16.17","24","15.14","45.09","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","30.28","22.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","23.75","78.45","","48.05","27.91","48.05","26","15.14","45.09","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","2814.00","2110.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1257.55","1257.55","1257.55","1 through 10","761.55","2207.58","other","ASC "
"Iliac Bone Augmentation","PX-76002510","CDM","27299","CPT","0761","RC","","","","both","","","1966.00","1474.50","MEDICARE [2001]","HB NWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1869.67","other","OPPS APC"
"Iliac Bone Augmentation","PX-76002510","CDM","27299","CPT","0761","RC","","","","outpatient","","","1966.00","1474.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1542.33","78.45","","25790.16","25790.16","25790.16","1 through 10","567.68","1542.33","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.67","1691.75","AETNA [1001]","HB CH AETNA HMO / PPO","1315.06","58.3","","2190.90","412.50","9264.59","16","1002.65","1757.39","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.67","1691.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1308.29","58","","1903.20","1903.20","3826.66","1 through 10","1002.65","1757.39","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.67","1691.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1409.79","62.5","","2186.25","2186.25","2186.25","32","1002.65","1757.39","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.67","1691.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1646.64","73","","5556.60","5556.60","5556.60","1 through 10","1002.65","1757.39","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.67","1691.75","WELLPOINT [1015]","HB CH WELLPOINT","1757.39","77.91","","1955.15","885.83","3150.40","26","1002.65","1757.39","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.67","1691.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1337.61","59.3","","831.03","253.22","2394.88","18","1127.84","1769.57","percent of total billed charges",""
"ILIAC WEDGE 8MM 15 GRAFT BONE ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010317","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.67","1691.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1769.57","78.45","","2481.69","1563.74","8149.28","1 through 10","1127.84","1769.57","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","1989.00","1491.75","AETNA [1001]","HB CH AETNA HMO / PPO","1159.59","58.3","","2190.90","412.50","9264.59","16","884.11","1549.63","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","1989.00","1491.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1153.62","58","","1903.20","1903.20","3826.66","1 through 10","884.11","1549.63","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","1989.00","1491.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1243.13","62.5","","2186.25","2186.25","2186.25","32","884.11","1549.63","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","1989.00","1491.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1451.97","73","","5556.60","5556.60","5556.60","1 through 10","884.11","1549.63","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","1989.00","1491.75","WELLPOINT [1015]","HB CH WELLPOINT","1549.63","77.91","","1955.15","885.83","3150.40","26","884.11","1549.63","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1989.00","1491.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1179.48","59.3","","831.03","253.22","2394.88","18","994.5","1560.37","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1989.00","1491.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1560.37","78.45","","2481.69","1563.74","8149.28","1 through 10","994.5","1560.37","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","both","","","3101.61","2326.21","AETNA [1001]","HB CH AETNA HMO / PPO","1808.24","58.3","","2190.90","412.50","9264.59","16","1378.67","2416.46","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","both","","","3101.61","2326.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1798.93","58","","1903.20","1903.20","3826.66","1 through 10","1378.67","2416.46","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","both","","","3101.61","2326.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1938.51","62.5","","2186.25","2186.25","2186.25","32","1378.67","2416.46","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","both","","","3101.61","2326.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2264.18","73","","5556.60","5556.60","5556.60","1 through 10","1378.67","2416.46","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","both","","","3101.61","2326.21","WELLPOINT [1015]","HB CH WELLPOINT","2416.46","77.91","","1955.15","885.83","3150.40","26","1378.67","2416.46","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3101.61","2326.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","1839.25","59.3","","831.03","253.22","2394.88","18","1550.81","2433.21","percent of total billed charges",""
"ILIAC WEDGE 9MM 25 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10010316","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3101.61","2326.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2433.21","78.45","","2481.69","1563.74","8149.28","1 through 10","1550.81","2433.21","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","3858.00","2893.50","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3005.77","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","3858.00","2893.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1237.95","3005.77","per diem",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","3858.00","2893.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1237.95","3005.77","per diem",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","outpatient","","","3858.00","2893.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2224.17","2224.17","2224.17","1 through 10","1237.95","4472.66","other","ASC "
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","outpatient","","","3858.00","2893.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2287.79","59.3","","9575.41","9575.41","9575.41","1 through 10","1237.95","4472.66","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","3408.00","2556.00","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","556.70","556.70","556.70","1 through 10","761.55","2655.17","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","782.00","586.50","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","347.6","860.54","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","outpatient","","","782.00","586.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","938.11","957.99","1 through 10","391","662.51","other","ASC "
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","AETNA [1001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","544.32","28","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","114.26","58","","192.00","192.00","192.00","1 through 10","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","114.26","58","","192.00","192.00","192.00","14","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","123.13","62.5","","192.00","192.00","192.00","17","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","87.48","87.48","87.48","1 through 10","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","147.61","147.61","147.61","1 through 10","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","WELLPOINT [1015]","HB CH WELLPOINT","153.48","77.91","","535.22","151.22","2263.22","60","87.57","153.48","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","109.82","112.51","38","98.5","154.55","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","147.61","147.61","1 through 10","98.5","154.55","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","87.48","147.61","55","98.5","154.55","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","AETNA [1001]","HB CH AETNA HMO / PPO","302.58","58.3","","1145.34","1145.34","1145.34","1 through 10","230.7","1456.11","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.16","196.16","196.16","1 through 10","230.7","1456.11","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.70","44.45","","388.25","388.25","388.25","1 through 10","230.7","1456.11","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","WELLPOINT [1015]","HB CH WELLPOINT","404.35","77.91","","795.48","391.23","795.48","1 through 10","230.7","1456.11","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","519.00","389.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","307.77","59.3","","295.93","280.85","295.93","1 through 10","204.8","926.86","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","407.16","78.45","","388.24","230.08","776.49","1 through 10","204.8","926.86","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","AETNA [1001]","HB CH AETNA HMO / PPO","210.46","58.3","","398.03","91.72","2388.21","18","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.12","50.06","200.24","15","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","263.53","73","","256.23","256.23","256.23","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.46","58.3","","199.02","199.02","199.02","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","407.00","264","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","TRICARE [160005]","HB NWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","193.33","203.50","1 through 10","160.46","768.52","other","Tricare OPPS"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","299.15","199.43","498.58","69","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","203.50","186.42","203.50","1 through 10","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.46","44.45","","159.92","159.92","269.85","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","91.35","199.43","16","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.46","44.45","","269.85","269.85","269.85","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","WELLPOINT [1015]","HB CH WELLPOINT","281.26","77.91","","627.45","276.45","978.45","42","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.07","59.3","","205.69","205.69","611.78","99","180.5","489.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","269.85","269.85","539.70","1 through 10","180.5","489.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","269.85","159.92","470.37","79","180.5","489.19","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","both","","","44.61","33.46","AETNA [1001]","HB CH AETNA HMO / PPO","26.01","58.3","","25.29","25.29","25.29","1 through 10","19.83","256.21","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","both","","","44.61","33.46","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","25.74","57.7","","26.90","24.64","48.98","1 through 10","19.83","256.21","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","both","","","44.61","33.46","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","32.16","72.1","","33.46","33.46","33.46","1 through 10","19.83","256.21","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","both","","","44.61","33.46","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","28.28","63.4","","29.44","29.44","33.46","1 through 10","19.83","256.21","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","44.61","33.46","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","25.74","57.7","","26.90","24.64","48.98","1 through 10","22.31","208.64","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","44.61","33.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.00","78.45","","34.30","34.30","34.30","1 through 10","22.31","208.64","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","AETNA [1001]","HB CH AETNA HMO / PPO","17.49","58.3","","16.44","16.44","16.45","18","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","17.40","58","","29.00","29.00","29.00","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","17.40","58","","29.00","29.00","29.00","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","18.75","62.5","","29.00","29.00","29.00","15","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","21.90","73","","16.44","16.44","16.44","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","30.00","22.50","WELLPOINT [1015]","HB CH WELLPOINT","23.37","77.91","","51.84","22.84","51.84","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","30.00","22.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","17.79","59.3","","16.99","16.99","17.00","13","13.34","23.54","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","30.00","22.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","23.54","78.45","","29.00","22.30","29.00","17","13.34","23.54","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","30.00","22.50","AETNA [1001]","HB CH AETNA HMO / PPO","17.49","58.3","","16.44","16.44","16.44","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","30.00","22.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","18.75","62.5","","29.00","29.00","29.00","1 through 10","15.9","23.37","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","77","14.67","232.43","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","CHAMPVA [160001]","HB NWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","32.00","32.00","32.00","1 through 10","14.67","232.43","other","Tricare OPPS"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","23","14.67","232.43","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.09","73","","18.30","18.14","18.30","1 through 10","14.67","232.43","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","TRICARE [160005]","HB NWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","84.52","84.52","84.52","1 through 10","14.67","232.43","other","Tricare OPPS"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","14.67","232.43","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.67","44.45","","24.60","14.37","24.60","1 through 10","14.67","232.43","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","14.67","232.43","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","WELLPOINT [1015]","HB CH WELLPOINT","25.71","77.91","","25.20","25.20","57.20","27","14.67","232.43","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.75","18.75","111","16.5","154.78","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","33.00","24.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.30","18.30","18.30","1 through 10","16.5","154.78","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","14.58","96.00","108","16.5","154.78","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","175","11.3","132.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","98.55","98.55","98.55","1 through 10","11.3","132.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","101.47","73","","95.63","95.63","95.63","1 through 10","11.3","132.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","TRICARE [160005]","HB NWH TRICARE","132.05","95","","13.89","13.89","26.39","1 through 10","11.3","132.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","61.51","103.79","1 through 10","11.3","132.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","79.11","177","11.81","109.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","103.79","61.51","103.79","159","11.81","109.05","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","113.00","84.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.01","59.3","","90.26","90.26","193.38","1 through 10","13.93","88.65","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.65","78.45","","84.57","84.57","84.57","1 through 10","13.93","88.65","percent of total billed charges",""
"Immunoassay Infectious Antibody Qn","PX-30001435","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","1 through 10","14.69","169.1","percent of total billed charges",""
"Immunoassay Infectious Antibody Qn","PX-30001435","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","202.76","1 through 10","15.46","139.64","percent of total billed charges",""
"Immunoassay Infectious Antibody Qn","PX-30001435","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","133.00","133.00","1 through 10","15.46","139.64","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","both","","","137.00","102.75","AETNA [1001]","HB CH AETNA HMO / PPO","79.87","58.3","","216.59","216.59","216.59","1 through 10","15.75","130.15","percent of total billed charges",""
"Immunoassay Optical Rsv","PX-30001352","CDM","87807","CPT","0306","RC","","","","both","","","97.00","72.75","AETNA [1001]","HB CH AETNA HMO / PPO","56.55","58.3","","53.30","53.30","53.30","1 through 10","12.84","92.15","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","16","16.2","129.2","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","396.00","14","11.81","106.69","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","60.14","101.48","1 through 10","11.81","106.69","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","1 through 10","21.45","135.72","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","129.16","129.16","1 through 10","21.45","135.72","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","245.00","183.75","AETNA [1001]","HB CH AETNA HMO / PPO","142.84","58.3","","134.95","134.95","134.95","38","20.39","232.75","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","245.00","183.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","178.85","73","","134.94","134.94","134.94","1 through 10","20.39","232.75","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","245.00","183.75","TRICARE [160005]","HB NWH TRICARE","232.75","95","","25.08","25.08","25.08","1 through 10","20.39","232.75","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.90","44.45","","108.43","108.43","108.43","1 through 10","20.39","232.75","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","245.00","183.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","145.29","59.3","","139.47","139.47","139.47","23","21.45","192.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","192.20","78.45","","182.98","182.97","182.98","20","21.45","192.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","both","","","174.00","130.50","AETNA [1001]","HB CH AETNA HMO / PPO","101.44","58.3","","95.82","95.82","95.82","1 through 10","20.39","165.3","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","both","","","174.00","130.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127.02","73","","92.50","92.49","92.50","1 through 10","20.39","165.3","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.18","59.3","","99.03","99.03","99.03","17","21.45","136.5","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.50","78.45","","129.93","129.93","129.93","1 through 10","21.45","136.5","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","20.39","122.82","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","73.25","11","21.45","131.19","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","73.25","1 through 10","21.45","131.19","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","56.95","56.95","56.95","1 through 10","21.45","131.19","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","outpatient","","","130.00","97.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.09","59.3","","369.18","369.18","369.18","1 through 10","12.36","101.99","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","both","","","262.00","196.50","AETNA [1001]","HB CH AETNA HMO / PPO","152.75","58.3","","144.59","144.59","144.59","1 through 10","28.76","248.9","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","both","","","262.00","196.50","TRICARE [160005]","HB NWH TRICARE","248.90","95","","35.37","35.37","35.37","1 through 10","28.76","248.9","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","262.00","196.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","155.37","59.3","","149.43","149.43","149.43","1 through 10","30.26","205.54","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","205.54","78.45","","196.04","196.04","196.04","1 through 10","30.26","205.54","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","17","21.89","176.7","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","106.07","1 through 10","23.04","145.92","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","82.46","139.15","11","23.04","145.92","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","AETNA [1001]","HB CH AETNA HMO / PPO","217.46","58.3","","205.82","205.82","205.82","1 through 10","165.8","1456.11","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","12","165.8","1456.11","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","165.8","1456.11","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","165.8","1456.11","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","373.00","279.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","221.19","59.3","","212.72","212.72","212.72","1 through 10","186.5","926.86","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","292.62","78.45","","279.07","279.07","279.07","1 through 10","186.5","926.86","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","AETNA [1001]","HB CH AETNA HMO / PPO","84.54","58.3","","79.95","79.95","79.95","91","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","104.55","72.1","","106.32","106.32","106.32","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","91.93","63.4","","93.49","93.49","186.97","29","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.85","73","","102.93","102.93","102.93","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.85","73","","205.86","205.86","205.86","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","TRICARE [160005]","HB NWH TRICARE","137.75","95","","41.62","41.62","41.62","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","WELLPOINT [1015]","HB CH WELLPOINT","112.97","77.91","","111.05","111.05","141.00","39","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.99","59.3","","82.63","82.63","413.13","81","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","83.67","57.7","","85.03","85.03","170.05","231","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","106.32","89.26","267.77","104","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","85.87","85.87","85.87","1 through 10","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","162.58","162.58","162.58","1 through 10","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","64.24","216.80","61","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","58.00","43.50","AETNA [1001]","HB CH AETNA HMO / PPO","33.81","58.3","","31.75","31.75","63.51","54","7.86","55.1","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","58.00","43.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.39","59.3","","32.82","32.82","111.57","21","3.8","45.5","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.50","78.45","","43.05","25.51","43.06","29","3.8","45.5","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","398.03","91.72","2388.21","18","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.12","50.06","200.24","15","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.93","73","","256.23","256.23","256.23","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.80","58.3","","199.02","199.02","199.02","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","407.00","264","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","TRICARE [160005]","HB NWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","193.33","203.50","1 through 10","151.57","768.52","other","Tricare OPPS"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","299.15","199.43","498.58","69","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","203.50","186.42","203.50","1 through 10","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.57","44.45","","159.92","159.92","269.85","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","91.35","199.43","16","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.57","44.45","","269.85","269.85","269.85","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","WELLPOINT [1015]","HB CH WELLPOINT","265.67","77.91","","627.45","276.45","978.45","42","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","205.69","205.69","611.78","99","170.5","489.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","269.85","269.85","539.70","1 through 10","170.5","489.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","269.85","159.92","470.37","79","170.5","489.19","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1145.00","858.75","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1088.9","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","573.65","50.1","","2255.00","204.62","2255.00","1 through 10","508.95","898.25","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","898.25","78.45","","1733.64","1733.64","1733.64","1 through 10","508.95","898.25","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1208.00","906.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1148.81","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","605.21","50.1","","2255.00","204.62","2255.00","1 through 10","536.96","947.68","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","947.68","78.45","","1733.64","1733.64","1733.64","1 through 10","536.96","947.68","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7669.14","7669.14","7669.14","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","10889.00","8166.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","9668.83","9668.83","9668.83","1 through 10","4472.66","8542.42","other","ASC "
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","10889.00","8166.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","5381.58","","Case rate ($5,381.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","24324.74","24324.74","24324.74","1 through 10","4472.66","8542.42","other","Multiple Surgery"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","MEDICARE [2001]","HB NWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7464.40","7793.84","1 through 10","5381.58","12774.9","other","OPPS APC"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1685.00","1685.00","1685.00","1 through 10","5381.58","12774.9","per diem",""
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.87","7645.87","7645.87","1 through 10","5381.58","12774.9","other","OPPS APC"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","outpatient","","","16397.00","12297.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","9887.65","9887.65","9887.65","1 through 10","1873.9","12863.45","other","ASC "
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","outpatient","","","16397.00","12297.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","12863.45","78.45","","5828.27","5828.27","5828.27","1 through 10","1873.9","12863.45","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","17259.56","17259.56","17259.56","1 through 10","666.75","1176.75","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","32650.00","24487.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25613.93","78.45","","17259.56","17259.56","17259.56","1 through 10","14512.93","25613.93","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","AETNA [1001]","HB CH AETNA HMO / PPO","2104.63","58.3","","1530.90","1160.93","1884.08","89","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1913.30","53","","5253.92","5253.92","5253.92","1 through 10","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2093.80","58","","12181.47","12181.47","12181.47","1 through 10","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2256.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1604.65","44.45","","1910.74","891.94","1910.74","1 through 10","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","both","","","3610.00","2707.50","WELLPOINT [1015]","HB CH WELLPOINT","2812.55","77.91","","1829.79","1561.50","2617.12","88","1604.65","2812.55","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3610.00","2707.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2140.73","59.3","","1359.46","1201.30","1689.00","61","1805","2832.05","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3610.00","2707.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2140.73","59.3","","1718.92","1718.92","1718.92","1 through 10","1805","2832.05","percent of total billed charges",""
"IMPLANT 12.2X27.4 5.8MM SIZE 1 PROSTHESIS THUMB SWANSON JOINT TRAPEZIUM","SUP-ITM-10079254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3610.00","2707.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2832.05","78.45","","1910.74","1019.06","2344.84","74","1805","2832.05","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","2190.90","412.50","9264.59","16","493.4","864.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","643.80","58","","1903.20","1903.20","3826.66","1 through 10","493.4","864.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","693.75","62.5","","2186.25","2186.25","2186.25","32","493.4","864.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","5556.60","5556.60","5556.60","1 through 10","493.4","864.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","WELLPOINT [1015]","HB CH WELLPOINT","864.80","77.91","","1955.15","885.83","3150.40","26","493.4","864.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","831.03","253.22","2394.88","18","555","870.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","2481.69","1563.74","8149.28","1 through 10","555","870.8","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1530.90","1160.93","1884.08","89","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","5253.92","5253.92","5253.92","1 through 10","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","12181.47","12181.47","12181.47","1 through 10","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","1350.68","1350.68","1350.68","1 through 10","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1910.74","891.94","1910.74","1 through 10","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","1829.79","1561.50","2617.12","88","733.43","1285.52","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1359.46","1201.30","1689.00","61","825","1294.43","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","1718.92","1718.92","1718.92","1 through 10","825","1294.43","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1910.74","1019.06","2344.84","74","825","1294.43","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","AETNA [1001]","HB CH AETNA HMO / PPO","585.92","58.3","","464.71","67.87","1012.10","221","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.92","58.3","","293.04","293.04","293.04","11","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.65","53","","983.89","983.89","983.89","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","582.90","58","","677.18","677.18","677.18","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","628.13","62.5","","46.58","46.58","46.58","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","747.15","747.15","747.15","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","1141.67","481.21","1141.67","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","76.54","76.54","76.54","1 through 10","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","WELLPOINT [1015]","HB CH WELLPOINT","783.00","77.91","","273.64","94.28","1367.51","138","446.72","783","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.97","59.3","","720.78","230.14","2010.94","427","502.5","788.42","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","595.97","59.3","","344.45","344.45","344.45","1 through 10","502.5","788.42","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","1120.13","1120.13","1120.13","1 through 10","502.5","788.42","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","456.17","105.33","1284.66","242","502.5","788.42","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","AETNA [1001]","HB CH AETNA HMO / PPO","666.45","58.3","","464.71","67.87","1012.10","221","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","666.45","58.3","","293.04","293.04","293.04","11","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","605.86","53","","983.89","983.89","983.89","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","663.02","58","","677.18","677.18","677.18","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","714.46","62.5","","46.58","46.58","46.58","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","834.49","73","","747.15","747.15","747.15","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.13","44.45","","1141.67","481.21","1141.67","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.13","44.45","","76.54","76.54","76.54","1 through 10","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","WELLPOINT [1015]","HB CH WELLPOINT","890.62","77.91","","273.64","94.28","1367.51","138","508.13","890.62","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","677.88","59.3","","720.78","230.14","2010.94","427","571.57","896.79","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","677.88","59.3","","344.45","344.45","344.45","1 through 10","571.57","896.79","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","896.79","78.45","","1120.13","1120.13","1120.13","1 through 10","571.57","896.79","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","896.79","78.45","","456.17","105.33","1284.66","242","571.57","896.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","AETNA [1001]","HB CH AETNA HMO / PPO","2331.84","58.3","","464.71","67.87","1012.10","221","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2331.84","58.3","","293.04","293.04","293.04","11","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2119.86","53","","983.89","983.89","983.89","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2319.84","58","","677.18","677.18","677.18","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2499.83","62.5","","46.58","46.58","46.58","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2919.80","73","","747.15","747.15","747.15","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.88","44.45","","1141.67","481.21","1141.67","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.88","44.45","","76.54","76.54","76.54","1 through 10","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","WELLPOINT [1015]","HB CH WELLPOINT","3116.19","77.91","","273.64","94.28","1367.51","138","1777.88","3116.19","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","2371.84","59.3","","720.78","230.14","2010.94","427","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2371.84","59.3","","344.45","344.45","344.45","1 through 10","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3137.79","78.45","","1120.13","1120.13","1120.13","1 through 10","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3137.79","78.45","","456.17","105.33","1284.66","242","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","AETNA [1001]","HB CH AETNA HMO / PPO","2513.70","58.3","","464.71","67.87","1012.10","221","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2513.70","58.3","","293.04","293.04","293.04","11","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2285.19","53","","983.89","983.89","983.89","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2500.77","58","","677.18","677.18","677.18","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2694.79","62.5","","46.58","46.58","46.58","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3147.52","73","","747.15","747.15","747.15","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1916.54","44.45","","1141.67","481.21","1141.67","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1916.54","44.45","","76.54","76.54","76.54","1 through 10","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","WELLPOINT [1015]","HB CH WELLPOINT","3359.22","77.91","","273.64","94.28","1367.51","138","1916.54","3359.22","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2556.82","59.3","","720.78","230.14","2010.94","427","2155.84","3382.51","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2556.82","59.3","","344.45","344.45","344.45","1 through 10","2155.84","3382.51","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3382.51","78.45","","1120.13","1120.13","1120.13","1 through 10","2155.84","3382.51","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3382.51","78.45","","456.17","105.33","1284.66","242","2155.84","3382.51","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","AETNA [1001]","HB CH AETNA HMO / PPO","981.19","58.3","","1530.90","1160.93","1884.08","89","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","891.99","53","","5253.92","5253.92","5253.92","1 through 10","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","976.14","58","","12181.47","12181.47","12181.47","1 through 10","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1051.88","62.5","","1350.68","1350.68","1350.68","1 through 10","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.09","44.45","","1910.74","891.94","1910.74","1 through 10","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","WELLPOINT [1015]","HB CH WELLPOINT","1311.23","77.91","","1829.79","1561.50","2617.12","88","748.09","1311.23","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1683.00","1262.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","998.02","59.3","","1359.46","1201.30","1689.00","61","841.5","1320.31","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1683.00","1262.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","998.02","59.3","","1718.92","1718.92","1718.92","1 through 10","841.5","1320.31","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1683.00","1262.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1320.31","78.45","","1910.74","1019.06","2344.84","74","841.5","1320.31","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","1530.90","1160.93","1884.08","89","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","5253.92","5253.92","5253.92","1 through 10","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2196.61","58","","12181.47","12181.47","12181.47","1 through 10","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2367.03","62.5","","1350.68","1350.68","1350.68","1 through 10","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","1910.74","891.94","1910.74","1 through 10","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","1829.79","1561.50","2617.12","88","1683.43","2950.65","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","1359.46","1201.30","1689.00","61","1893.63","2971.1","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2245.84","59.3","","1718.92","1718.92","1718.92","1 through 10","1893.63","2971.1","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","1910.74","1019.06","2344.84","74","1893.63","2971.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","AETNA [1001]","HB CH AETNA HMO / PPO","4028.10","58.3","","1530.90","1160.93","1884.08","89","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3661.91","53","","5253.92","5253.92","5253.92","1 through 10","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4007.38","58","","12181.47","12181.47","12181.47","1 through 10","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4318.29","62.5","","1350.68","1350.68","1350.68","1 through 10","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3071.17","44.45","","1910.74","891.94","1910.74","1 through 10","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","WELLPOINT [1015]","HB CH WELLPOINT","5383.01","77.91","","1829.79","1561.50","2617.12","88","3071.17","5383.01","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6909.27","5181.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","4097.20","59.3","","1359.46","1201.30","1689.00","61","3454.64","5420.32","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6909.27","5181.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4097.20","59.3","","1718.92","1718.92","1718.92","1 through 10","3454.64","5420.32","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6909.27","5181.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5420.32","78.45","","1910.74","1019.06","2344.84","74","3454.64","5420.32","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","both","","","735.00","551.25","AETNA [1001]","HB CH AETNA HMO / PPO","428.51","58.3","","416.75","416.75","416.75","1 through 10","326.71","572.64","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.86","59.3","","7893.60","423.68","7893.60","1 through 10","367.5","576.61","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.61","78.45","","555.84","329.40","555.84","1 through 10","367.5","576.61","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","AETNA [1001]","HB CH AETNA HMO / PPO","585.76","58.3","","464.71","67.87","1012.10","221","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.76","58.3","","293.04","293.04","293.04","11","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.51","53","","983.89","983.89","983.89","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","582.75","58","","677.18","677.18","677.18","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","627.96","62.5","","46.58","46.58","46.58","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.46","73","","747.15","747.15","747.15","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.61","44.45","","1141.67","481.21","1141.67","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.61","44.45","","76.54","76.54","76.54","1 through 10","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","WELLPOINT [1015]","HB CH WELLPOINT","782.79","77.91","","273.64","94.28","1367.51","138","446.61","782.79","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.81","59.3","","720.78","230.14","2010.94","427","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","595.81","59.3","","344.45","344.45","344.45","1 through 10","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","788.22","78.45","","1120.13","1120.13","1120.13","1 through 10","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.22","78.45","","456.17","105.33","1284.66","242","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","AETNA [1001]","HB CH AETNA HMO / PPO","2484.68","58.3","","464.71","67.87","1012.10","221","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2484.68","58.3","","293.04","293.04","293.04","11","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2258.80","53","","983.89","983.89","983.89","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2471.90","58","","677.18","677.18","677.18","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2663.68","62.5","","46.58","46.58","46.58","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3111.18","73","","747.15","747.15","747.15","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.41","44.45","","1141.67","481.21","1141.67","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.41","44.45","","76.54","76.54","76.54","1 through 10","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","WELLPOINT [1015]","HB CH WELLPOINT","3320.44","77.91","","273.64","94.28","1367.51","138","1894.41","3320.44","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","2527.30","59.3","","720.78","230.14","2010.94","427","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2527.30","59.3","","344.45","344.45","344.45","1 through 10","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3343.45","78.45","","1120.13","1120.13","1120.13","1 through 10","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3343.45","78.45","","456.17","105.33","1284.66","242","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","AETNA [1001]","HB CH AETNA HMO / PPO","3919.22","58.3","","464.71","67.87","1012.10","221","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3919.22","58.3","","293.04","293.04","293.04","11","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3562.93","53","","983.89","983.89","983.89","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3899.05","58","","677.18","677.18","677.18","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4201.56","62.5","","46.58","46.58","46.58","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4907.43","73","","747.15","747.15","747.15","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2988.15","44.45","","1141.67","481.21","1141.67","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2988.15","44.45","","76.54","76.54","76.54","1 through 10","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","WELLPOINT [1015]","HB CH WELLPOINT","5237.50","77.91","","273.64","94.28","1367.51","138","2988.15","5237.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","3986.44","59.3","","720.78","230.14","2010.94","427","3361.25","5273.8","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3986.44","59.3","","344.45","344.45","344.45","1 through 10","3361.25","5273.8","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5273.80","78.45","","1120.13","1120.13","1120.13","1 through 10","3361.25","5273.8","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5273.80","78.45","","456.17","105.33","1284.66","242","3361.25","5273.8","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2070.70","1553.02","AETNA [1001]","HB CH AETNA HMO / PPO","1207.22","58.3","","1770.74","1316.58","1770.74","15","1097.47","1613.28","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2070.70","1553.02","WELLPOINT [1015]","HB CH WELLPOINT","1613.28","77.91","","2459.68","2459.68","2488.41","1 through 10","1097.47","1613.28","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2070.70","1553.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1227.93","59.3","","1830.08","1830.08","1830.08","11","920.43","1624.46","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2070.70","1553.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1624.46","78.45","","2400.96","2400.96","2400.96","1 through 10","920.43","1624.46","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","AETNA [1001]","HB CH AETNA HMO / PPO","3089.90","58.3","","1770.74","1316.58","1770.74","15","2809","4129.23","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","WELLPOINT [1015]","HB CH WELLPOINT","4129.23","77.91","","2459.68","2459.68","2488.41","1 through 10","2809","4129.23","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3142.90","59.3","","1830.08","1830.08","1830.08","11","2355.85","4157.85","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4157.85","78.45","","2400.96","2400.96","2400.96","1 through 10","2355.85","4157.85","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","AETNA [1001]","HB CH AETNA HMO / PPO","476.84","58.3","","464.71","67.87","1012.10","221","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","476.84","58.3","","293.04","293.04","293.04","11","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","433.49","53","","983.89","983.89","983.89","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","474.38","58","","677.18","677.18","677.18","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","511.19","62.5","","46.58","46.58","46.58","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","597.07","73","","747.15","747.15","747.15","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.56","44.45","","1141.67","481.21","1141.67","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.56","44.45","","76.54","76.54","76.54","1 through 10","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","WELLPOINT [1015]","HB CH WELLPOINT","637.23","77.91","","273.64","94.28","1367.51","138","363.56","637.23","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.01","59.3","","720.78","230.14","2010.94","427","408.95","641.64","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","485.01","59.3","","344.45","344.45","344.45","1 through 10","408.95","641.64","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","641.64","78.45","","1120.13","1120.13","1120.13","1 through 10","408.95","641.64","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","641.64","78.45","","456.17","105.33","1284.66","242","408.95","641.64","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","AETNA [1001]","HB CH AETNA HMO / PPO","1938.71","58.3","","464.71","67.87","1012.10","221","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1938.71","58.3","","293.04","293.04","293.04","11","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1762.46","53","","983.89","983.89","983.89","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1928.73","58","","677.18","677.18","677.18","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2078.38","62.5","","46.58","46.58","46.58","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2427.54","73","","747.15","747.15","747.15","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.14","44.45","","1141.67","481.21","1141.67","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.14","44.45","","76.54","76.54","76.54","1 through 10","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","WELLPOINT [1015]","HB CH WELLPOINT","2590.82","77.91","","273.64","94.28","1367.51","138","1478.14","2590.82","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1971.96","59.3","","720.78","230.14","2010.94","427","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1971.96","59.3","","344.45","344.45","344.45","1 through 10","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2608.78","78.45","","1120.13","1120.13","1120.13","1 through 10","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2608.78","78.45","","456.17","105.33","1284.66","242","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","AETNA [1001]","HB CH AETNA HMO / PPO","2553.82","58.3","","464.71","67.87","1012.10","221","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2553.82","58.3","","293.04","293.04","293.04","11","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2321.65","53","","983.89","983.89","983.89","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2540.68","58","","677.18","677.18","677.18","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2737.80","62.5","","46.58","46.58","46.58","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3197.75","73","","747.15","747.15","747.15","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.12","44.45","","1141.67","481.21","1141.67","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.12","44.45","","76.54","76.54","76.54","1 through 10","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","WELLPOINT [1015]","HB CH WELLPOINT","3412.83","77.91","","273.64","94.28","1367.51","138","1947.12","3412.83","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","2597.62","59.3","","720.78","230.14","2010.94","427","2190.24","3436.49","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2597.62","59.3","","344.45","344.45","344.45","1 through 10","2190.24","3436.49","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3436.49","78.45","","1120.13","1120.13","1120.13","1 through 10","2190.24","3436.49","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3436.49","78.45","","456.17","105.33","1284.66","242","2190.24","3436.49","percent of total billed charges",""
"IMPLANT EAR .06X11MM SCHUKNECHT CRESCENT FLUOROPLASTIC","SUP-ITM-10214792","CDM","L8613","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.66","59.3","","782.24","782.24","782.24","1 through 10","88.25","138.46","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","AETNA [1001]","HB CH AETNA HMO / PPO","1764.94","58.3","","1530.90","1160.93","1884.08","89","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1604.49","53","","5253.92","5253.92","5253.92","1 through 10","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1755.86","58","","12181.47","12181.47","12181.47","1 through 10","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1892.09","62.5","","1350.68","1350.68","1350.68","1 through 10","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1345.65","44.45","","1910.74","891.94","1910.74","1 through 10","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","WELLPOINT [1015]","HB CH WELLPOINT","2358.60","77.91","","1829.79","1561.50","2617.12","88","1345.65","2358.6","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.34","2270.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1795.21","59.3","","1359.46","1201.30","1689.00","61","1513.67","2374.95","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.34","2270.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1795.21","59.3","","1718.92","1718.92","1718.92","1 through 10","1513.67","2374.95","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.34","2270.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2374.95","78.45","","1910.74","1019.06","2344.84","74","1513.67","2374.95","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","AETNA [1001]","HB CH AETNA HMO / PPO","2202.57","58.3","","1530.90","1160.93","1884.08","89","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2002.34","53","","5253.92","5253.92","5253.92","1 through 10","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2191.24","58","","12181.47","12181.47","12181.47","1 through 10","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2361.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.32","44.45","","1910.74","891.94","1910.74","1 through 10","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","WELLPOINT [1015]","HB CH WELLPOINT","2943.44","77.91","","1829.79","1561.50","2617.12","88","1679.32","2943.44","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3778.00","2833.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2240.35","59.3","","1359.46","1201.30","1689.00","61","1889","2963.84","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3778.00","2833.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2240.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1889","2963.84","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3778.00","2833.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2963.84","78.45","","1910.74","1019.06","2344.84","74","1889","2963.84","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","AETNA [1001]","HB CH AETNA HMO / PPO","3596.54","58.3","","1530.90","1160.93","1884.08","89","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3269.58","53","","5253.92","5253.92","5253.92","1 through 10","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3578.03","58","","12181.47","12181.47","12181.47","1 through 10","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3855.64","62.5","","1350.68","1350.68","1350.68","1 through 10","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2742.13","44.45","","1910.74","891.94","1910.74","1 through 10","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","WELLPOINT [1015]","HB CH WELLPOINT","4806.28","77.91","","1829.79","1561.50","2617.12","88","2742.13","4806.28","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6169.02","4626.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","3658.23","59.3","","1359.46","1201.30","1689.00","61","3084.51","4839.6","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6169.02","4626.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3658.23","59.3","","1718.92","1718.92","1718.92","1 through 10","3084.51","4839.6","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6169.02","4626.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4839.60","78.45","","1910.74","1019.06","2344.84","74","3084.51","4839.6","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","AETNA [1001]","HB CH AETNA HMO / PPO","365.38","58.3","","464.71","67.87","1012.10","221","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.38","58.3","","293.04","293.04","293.04","11","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.17","53","","983.89","983.89","983.89","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","363.50","58","","677.18","677.18","677.18","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","391.71","62.5","","46.58","46.58","46.58","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.51","73","","747.15","747.15","747.15","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.58","44.45","","1141.67","481.21","1141.67","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.58","44.45","","76.54","76.54","76.54","1 through 10","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","WELLPOINT [1015]","HB CH WELLPOINT","488.29","77.91","","273.64","94.28","1367.51","138","278.58","488.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.65","59.3","","720.78","230.14","2010.94","427","313.37","491.67","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","371.65","59.3","","344.45","344.45","344.45","1 through 10","313.37","491.67","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","491.67","78.45","","1120.13","1120.13","1120.13","1 through 10","313.37","491.67","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.67","78.45","","456.17","105.33","1284.66","242","313.37","491.67","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","AETNA [1001]","HB CH AETNA HMO / PPO","102025.00","58.3","","2190.90","412.50","9264.59","16","77787.5","136342.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","101500.00","58","","1903.20","1903.20","3826.66","1 through 10","77787.5","136342.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","109375.00","62.5","","2186.25","2186.25","2186.25","32","77787.5","136342.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127750.00","73","","5556.60","5556.60","5556.60","1 through 10","77787.5","136342.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","WELLPOINT [1015]","HB CH WELLPOINT","136342.50","77.91","","1955.15","885.83","3150.40","26","77787.5","136342.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175000.00","131250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","103775.00","59.3","","831.03","253.22","2394.88","18","87500","137287.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175000.00","131250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137287.50","78.45","","2481.69","1563.74","8149.28","1 through 10","87500","137287.5","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","AETNA [1001]","HB CH AETNA HMO / PPO","957.96","58.3","","1530.90","1160.93","1884.08","89","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","870.87","53","","5253.92","5253.92","5253.92","1 through 10","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","953.03","58","","12181.47","12181.47","12181.47","1 through 10","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1026.98","62.5","","1350.68","1350.68","1350.68","1 through 10","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","730.38","44.45","","1910.74","891.94","1910.74","1 through 10","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","WELLPOINT [1015]","HB CH WELLPOINT","1280.19","77.91","","1829.79","1561.50","2617.12","88","730.38","1280.19","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1643.16","1232.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","974.39","59.3","","1359.46","1201.30","1689.00","61","821.58","1289.06","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1643.16","1232.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","974.39","59.3","","1718.92","1718.92","1718.92","1 through 10","821.58","1289.06","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1643.16","1232.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1289.06","78.45","","1910.74","1019.06","2344.84","74","821.58","1289.06","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","AETNA [1001]","HB CH AETNA HMO / PPO","2325.66","58.3","","1530.90","1160.93","1884.08","89","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.24","53","","5253.92","5253.92","5253.92","1 through 10","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2313.70","58","","12181.47","12181.47","12181.47","1 through 10","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2493.21","62.5","","1350.68","1350.68","1350.68","1 through 10","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.17","44.45","","1910.74","891.94","1910.74","1 through 10","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","WELLPOINT [1015]","HB CH WELLPOINT","3107.93","77.91","","1829.79","1561.50","2617.12","88","1773.17","3107.93","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3989.13","2991.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","2365.55","59.3","","1359.46","1201.30","1689.00","61","1994.57","3129.47","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3989.13","2991.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2365.55","59.3","","1718.92","1718.92","1718.92","1 through 10","1994.57","3129.47","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3989.13","2991.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3129.47","78.45","","1910.74","1019.06","2344.84","74","1994.57","3129.47","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","AETNA [1001]","HB CH AETNA HMO / PPO","2544.85","58.3","","1530.90","1160.93","1884.08","89","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2313.50","53","","5253.92","5253.92","5253.92","1 through 10","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2531.75","58","","12181.47","12181.47","12181.47","1 through 10","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2728.18","62.5","","1350.68","1350.68","1350.68","1 through 10","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1940.28","44.45","","1910.74","891.94","1910.74","1 through 10","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","WELLPOINT [1015]","HB CH WELLPOINT","3400.84","77.91","","1829.79","1561.50","2617.12","88","1940.28","3400.84","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4365.09","3273.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","2588.50","59.3","","1359.46","1201.30","1689.00","61","2182.55","3424.41","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4365.09","3273.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2588.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2182.55","3424.41","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4365.09","3273.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3424.41","78.45","","1910.74","1019.06","2344.84","74","2182.55","3424.41","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","AETNA [1001]","HB CH AETNA HMO / PPO","2055.08","58.3","","464.71","67.87","1012.10","221","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2055.08","58.3","","293.04","293.04","293.04","11","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1868.25","53","","983.89","983.89","983.89","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2044.50","58","","677.18","677.18","677.18","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2203.13","62.5","","46.58","46.58","46.58","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2573.25","73","","747.15","747.15","747.15","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","1141.67","481.21","1141.67","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","76.54","76.54","76.54","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","WELLPOINT [1015]","HB CH WELLPOINT","2746.33","77.91","","273.64","94.28","1367.51","138","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2090.33","59.3","","720.78","230.14","2010.94","427","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2090.33","59.3","","344.45","344.45","344.45","1 through 10","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INATE 4.5MM X45MM","SUP-ITM-10322245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","456.17","105.33","1284.66","242","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","AETNA [1001]","HB CH AETNA HMO / PPO","2055.08","58.3","","464.71","67.87","1012.10","221","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2055.08","58.3","","293.04","293.04","293.04","11","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1868.25","53","","983.89","983.89","983.89","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2044.50","58","","677.18","677.18","677.18","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2203.13","62.5","","46.58","46.58","46.58","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2573.25","73","","747.15","747.15","747.15","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","1141.67","481.21","1141.67","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","76.54","76.54","76.54","1 through 10","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","WELLPOINT [1015]","HB CH WELLPOINT","2746.33","77.91","","273.64","94.28","1367.51","138","1566.86","2746.33","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2090.33","59.3","","720.78","230.14","2010.94","427","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2090.33","59.3","","344.45","344.45","344.45","1 through 10","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1762.5","2765.36","percent of total billed charges",""
"IMPLANT INNATE 3.6MM X 40MM","SUP-ITM-10327973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","456.17","105.33","1284.66","242","1762.5","2765.36","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","AETNA [1001]","HB CH AETNA HMO / PPO","1112.90","58.3","","1530.90","1160.93","1884.08","89","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1011.73","53","","5253.92","5253.92","5253.92","1 through 10","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1107.17","58","","12181.47","12181.47","12181.47","1 through 10","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1193.08","62.5","","1350.68","1350.68","1350.68","1 through 10","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.51","44.45","","1910.74","891.94","1910.74","1 through 10","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","WELLPOINT [1015]","HB CH WELLPOINT","1487.24","77.91","","1829.79","1561.50","2617.12","88","848.51","1487.24","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1908.92","1431.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","1131.99","59.3","","1359.46","1201.30","1689.00","61","954.46","1497.55","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1908.92","1431.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1131.99","59.3","","1718.92","1718.92","1718.92","1 through 10","954.46","1497.55","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1908.92","1431.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1497.55","78.45","","1910.74","1019.06","2344.84","74","954.46","1497.55","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","AETNA [1001]","HB CH AETNA HMO / PPO","2138.99","58.3","","1530.90","1160.93","1884.08","89","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1944.53","53","","5253.92","5253.92","5253.92","1 through 10","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2127.98","58","","12181.47","12181.47","12181.47","1 through 10","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2293.08","62.5","","1350.68","1350.68","1350.68","1 through 10","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.84","44.45","","1910.74","891.94","1910.74","1 through 10","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","WELLPOINT [1015]","HB CH WELLPOINT","2858.46","77.91","","1829.79","1561.50","2617.12","88","1630.84","2858.46","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3668.93","2751.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2175.68","59.3","","1359.46","1201.30","1689.00","61","1834.47","2878.28","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3668.93","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2175.68","59.3","","1718.92","1718.92","1718.92","1 through 10","1834.47","2878.28","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3668.93","2751.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2878.28","78.45","","1910.74","1019.06","2344.84","74","1834.47","2878.28","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","AETNA [1001]","HB CH AETNA HMO / PPO","3564.82","58.3","","1530.90","1160.93","1884.08","89","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3240.75","53","","5253.92","5253.92","5253.92","1 through 10","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3546.48","58","","12181.47","12181.47","12181.47","1 through 10","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3821.64","62.5","","1350.68","1350.68","1350.68","1 through 10","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2717.95","44.45","","1910.74","891.94","1910.74","1 through 10","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","WELLPOINT [1015]","HB CH WELLPOINT","4763.90","77.91","","1829.79","1561.50","2617.12","88","2717.95","4763.9","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6114.62","4585.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","3625.97","59.3","","1359.46","1201.30","1689.00","61","3057.31","4796.92","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6114.62","4585.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3625.97","59.3","","1718.92","1718.92","1718.92","1 through 10","3057.31","4796.92","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6114.62","4585.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4796.92","78.45","","1910.74","1019.06","2344.84","74","3057.31","4796.92","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","AETNA [1001]","HB CH AETNA HMO / PPO","2681.80","58.3","","416.75","416.75","416.75","1 through 10","2044.7","3583.86","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.80","59.3","","7893.60","423.68","7893.60","1 through 10","2300","3608.7","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3608.70","78.45","","555.84","329.40","555.84","1 through 10","2300","3608.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","AETNA [1001]","HB CH AETNA HMO / PPO","207.12","58.3","","464.71","67.87","1012.10","221","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","207.12","58.3","","293.04","293.04","293.04","11","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","188.29","53","","983.89","983.89","983.89","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","206.05","58","","677.18","677.18","677.18","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","222.04","62.5","","46.58","46.58","46.58","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","259.34","73","","747.15","747.15","747.15","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.91","44.45","","1141.67","481.21","1141.67","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.91","44.45","","76.54","76.54","76.54","1 through 10","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","WELLPOINT [1015]","HB CH WELLPOINT","276.78","77.91","","273.64","94.28","1367.51","138","157.91","276.78","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.67","59.3","","720.78","230.14","2010.94","427","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","210.67","59.3","","344.45","344.45","344.45","1 through 10","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","278.70","78.45","","1120.13","1120.13","1120.13","1 through 10","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.70","78.45","","456.17","105.33","1284.66","242","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","AETNA [1001]","HB CH AETNA HMO / PPO","2237.31","58.3","","464.71","67.87","1012.10","221","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2237.31","58.3","","293.04","293.04","293.04","11","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2033.92","53","","983.89","983.89","983.89","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2225.80","58","","677.18","677.18","677.18","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2398.49","62.5","","46.58","46.58","46.58","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2801.44","73","","747.15","747.15","747.15","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.81","44.45","","1141.67","481.21","1141.67","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.81","44.45","","76.54","76.54","76.54","1 through 10","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","WELLPOINT [1015]","HB CH WELLPOINT","2989.87","77.91","","273.64","94.28","1367.51","138","1705.81","2989.87","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2275.69","59.3","","720.78","230.14","2010.94","427","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2275.69","59.3","","344.45","344.45","344.45","1 through 10","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3010.59","78.45","","1120.13","1120.13","1120.13","1 through 10","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3010.59","78.45","","456.17","105.33","1284.66","242","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","AETNA [1001]","HB CH AETNA HMO / PPO","2647.60","58.3","","464.71","67.87","1012.10","221","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2647.60","58.3","","293.04","293.04","293.04","11","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2406.90","53","","983.89","983.89","983.89","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2633.97","58","","677.18","677.18","677.18","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2838.33","62.5","","46.58","46.58","46.58","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3315.17","73","","747.15","747.15","747.15","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2018.62","44.45","","1141.67","481.21","1141.67","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2018.62","44.45","","76.54","76.54","76.54","1 through 10","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","WELLPOINT [1015]","HB CH WELLPOINT","3538.15","77.91","","273.64","94.28","1367.51","138","2018.62","3538.15","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2693.01","59.3","","720.78","230.14","2010.94","427","2270.67","3562.67","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2693.01","59.3","","344.45","344.45","344.45","1 through 10","2270.67","3562.67","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3562.67","78.45","","1120.13","1120.13","1120.13","1 through 10","2270.67","3562.67","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3562.67","78.45","","456.17","105.33","1284.66","242","2270.67","3562.67","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","AETNA [1001]","HB CH AETNA HMO / PPO","184.86","58.3","","464.71","67.87","1012.10","221","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","184.86","58.3","","293.04","293.04","293.04","11","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.06","53","","983.89","983.89","983.89","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","183.91","58","","677.18","677.18","677.18","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.18","62.5","","46.58","46.58","46.58","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","231.48","73","","747.15","747.15","747.15","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.95","44.45","","1141.67","481.21","1141.67","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.95","44.45","","76.54","76.54","76.54","1 through 10","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","WELLPOINT [1015]","HB CH WELLPOINT","247.04","77.91","","273.64","94.28","1367.51","138","140.95","247.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.03","59.3","","720.78","230.14","2010.94","427","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.03","59.3","","344.45","344.45","344.45","1 through 10","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","248.76","78.45","","1120.13","1120.13","1120.13","1 through 10","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.76","78.45","","456.17","105.33","1284.66","242","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","AETNA [1001]","HB CH AETNA HMO / PPO","2031.61","58.3","","464.71","67.87","1012.10","221","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.61","58.3","","293.04","293.04","293.04","11","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.92","53","","983.89","983.89","983.89","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2021.16","58","","677.18","677.18","677.18","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2177.97","62.5","","46.58","46.58","46.58","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.87","73","","747.15","747.15","747.15","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.97","44.45","","1141.67","481.21","1141.67","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.97","44.45","","76.54","76.54","76.54","1 through 10","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","WELLPOINT [1015]","HB CH WELLPOINT","2714.97","77.91","","273.64","94.28","1367.51","138","1548.97","2714.97","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.46","59.3","","720.78","230.14","2010.94","427","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2066.46","59.3","","344.45","344.45","344.45","1 through 10","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2733.79","78.45","","1120.13","1120.13","1120.13","1 through 10","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.79","78.45","","456.17","105.33","1284.66","242","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","AETNA [1001]","HB CH AETNA HMO / PPO","2840.38","58.3","","464.71","67.87","1012.10","221","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2840.38","58.3","","293.04","293.04","293.04","11","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2582.16","53","","983.89","983.89","983.89","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2825.76","58","","677.18","677.18","677.18","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3045.00","62.5","","46.58","46.58","46.58","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3556.56","73","","747.15","747.15","747.15","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2165.60","44.45","","1141.67","481.21","1141.67","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2165.60","44.45","","76.54","76.54","76.54","1 through 10","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","WELLPOINT [1015]","HB CH WELLPOINT","3795.78","77.91","","273.64","94.28","1367.51","138","2165.6","3795.78","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2889.10","59.3","","720.78","230.14","2010.94","427","2436","3822.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2889.10","59.3","","344.45","344.45","344.45","1 through 10","2436","3822.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3822.08","78.45","","1120.13","1120.13","1120.13","1 through 10","2436","3822.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3822.08","78.45","","456.17","105.33","1284.66","242","2436","3822.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","AETNA [1001]","HB CH AETNA HMO / PPO","536.48","58.3","","464.71","67.87","1012.10","221","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","536.48","58.3","","293.04","293.04","293.04","11","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","487.71","53","","983.89","983.89","983.89","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","533.72","58","","677.18","677.18","677.18","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","575.13","62.5","","46.58","46.58","46.58","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","671.75","73","","747.15","747.15","747.15","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.03","44.45","","1141.67","481.21","1141.67","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.03","44.45","","76.54","76.54","76.54","1 through 10","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","WELLPOINT [1015]","HB CH WELLPOINT","716.94","77.91","","273.64","94.28","1367.51","138","409.03","716.94","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","545.68","59.3","","720.78","230.14","2010.94","427","460.11","721.9","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","545.68","59.3","","344.45","344.45","344.45","1 through 10","460.11","721.9","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","721.90","78.45","","1120.13","1120.13","1120.13","1 through 10","460.11","721.9","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","721.90","78.45","","456.17","105.33","1284.66","242","460.11","721.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","AETNA [1001]","HB CH AETNA HMO / PPO","2060.74","58.3","","464.71","67.87","1012.10","221","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2060.74","58.3","","293.04","293.04","293.04","11","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.40","53","","983.89","983.89","983.89","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2050.14","58","","677.18","677.18","677.18","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2209.20","62.5","","46.58","46.58","46.58","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2580.35","73","","747.15","747.15","747.15","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.18","44.45","","1141.67","481.21","1141.67","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.18","44.45","","76.54","76.54","76.54","1 through 10","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","WELLPOINT [1015]","HB CH WELLPOINT","2753.90","77.91","","273.64","94.28","1367.51","138","1571.18","2753.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","2096.09","59.3","","720.78","230.14","2010.94","427","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2096.09","59.3","","344.45","344.45","344.45","1 through 10","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2772.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2772.99","78.45","","456.17","105.33","1284.66","242","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","AETNA [1001]","HB CH AETNA HMO / PPO","3405.02","58.3","","464.71","67.87","1012.10","221","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3405.02","58.3","","293.04","293.04","293.04","11","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3095.47","53","","983.89","983.89","983.89","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3387.50","58","","677.18","677.18","677.18","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3650.32","62.5","","46.58","46.58","46.58","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4263.57","73","","747.15","747.15","747.15","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2596.11","44.45","","1141.67","481.21","1141.67","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2596.11","44.45","","76.54","76.54","76.54","1 through 10","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","WELLPOINT [1015]","HB CH WELLPOINT","4550.34","77.91","","273.64","94.28","1367.51","138","2596.11","4550.34","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","3463.42","59.3","","720.78","230.14","2010.94","427","2920.26","4581.88","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3463.42","59.3","","344.45","344.45","344.45","1 through 10","2920.26","4581.88","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4581.88","78.45","","1120.13","1120.13","1120.13","1 through 10","2920.26","4581.88","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.88","78.45","","456.17","105.33","1284.66","242","2920.26","4581.88","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","AETNA [1001]","HB CH AETNA HMO / PPO","1379.61","58.3","","1530.90","1160.93","1884.08","89","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1254.19","53","","5253.92","5253.92","5253.92","1 through 10","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1372.51","58","","12181.47","12181.47","12181.47","1 through 10","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1479.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.86","44.45","","1910.74","891.94","1910.74","1 through 10","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","WELLPOINT [1015]","HB CH WELLPOINT","1843.66","77.91","","1829.79","1561.50","2617.12","88","1051.86","1843.66","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2366.40","1774.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1403.28","59.3","","1359.46","1201.30","1689.00","61","1183.2","1856.44","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2366.40","1774.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1403.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1183.2","1856.44","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2366.40","1774.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1856.44","78.45","","1910.74","1019.06","2344.84","74","1183.2","1856.44","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","AETNA [1001]","HB CH AETNA HMO / PPO","2335.33","58.3","","1530.90","1160.93","1884.08","89","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2123.03","53","","5253.92","5253.92","5253.92","1 through 10","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2323.32","58","","12181.47","12181.47","12181.47","1 through 10","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2503.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1780.54","44.45","","1910.74","891.94","1910.74","1 through 10","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","WELLPOINT [1015]","HB CH WELLPOINT","3120.86","77.91","","1829.79","1561.50","2617.12","88","1780.54","3120.86","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4005.72","3004.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","2375.39","59.3","","1359.46","1201.30","1689.00","61","2002.86","3142.49","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4005.72","3004.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2375.39","59.3","","1718.92","1718.92","1718.92","1 through 10","2002.86","3142.49","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4005.72","3004.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3142.49","78.45","","1910.74","1019.06","2344.84","74","2002.86","3142.49","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","AETNA [1001]","HB CH AETNA HMO / PPO","2965.15","58.3","","1530.90","1160.93","1884.08","89","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2695.59","53","","5253.92","5253.92","5253.92","1 through 10","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2949.89","58","","12181.47","12181.47","12181.47","1 through 10","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3178.76","62.5","","1350.68","1350.68","1350.68","1 through 10","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2260.74","44.45","","1910.74","891.94","1910.74","1 through 10","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","WELLPOINT [1015]","HB CH WELLPOINT","3962.52","77.91","","1829.79","1561.50","2617.12","88","2260.74","3962.52","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5086.02","3814.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","3016.01","59.3","","1359.46","1201.30","1689.00","61","2543.01","3989.98","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5086.02","3814.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3016.01","59.3","","1718.92","1718.92","1718.92","1 through 10","2543.01","3989.98","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5086.02","3814.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3989.98","78.45","","1910.74","1019.06","2344.84","74","2543.01","3989.98","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","AETNA [1001]","HB CH AETNA HMO / PPO","582.36","58.3","","2190.90","412.50","9264.59","16","444.02","778.25","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","579.37","58","","1903.20","1903.20","3826.66","1 through 10","444.02","778.25","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","624.32","62.5","","2186.25","2186.25","2186.25","32","444.02","778.25","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","729.20","73","","5556.60","5556.60","5556.60","1 through 10","444.02","778.25","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","WELLPOINT [1015]","HB CH WELLPOINT","778.25","77.91","","1955.15","885.83","3150.40","26","444.02","778.25","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.91","749.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","592.35","59.3","","831.03","253.22","2394.88","18","499.46","783.64","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.91","749.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","783.64","78.45","","2481.69","1563.74","8149.28","1 through 10","499.46","783.64","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","AETNA [1001]","HB CH AETNA HMO / PPO","2226.65","58.3","","2190.90","412.50","9264.59","16","1697.67","2975.61","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2215.19","58","","1903.20","1903.20","3826.66","1 through 10","1697.67","2975.61","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2387.06","62.5","","2186.25","2186.25","2186.25","32","1697.67","2975.61","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2788.08","73","","5556.60","5556.60","5556.60","1 through 10","1697.67","2975.61","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","WELLPOINT [1015]","HB CH WELLPOINT","2975.61","77.91","","1955.15","885.83","3150.40","26","1697.67","2975.61","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3819.29","2864.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2264.84","59.3","","831.03","253.22","2394.88","18","1909.65","2996.23","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3819.29","2864.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2996.23","78.45","","2481.69","1563.74","8149.28","1 through 10","1909.65","2996.23","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","AETNA [1001]","HB CH AETNA HMO / PPO","3545.23","58.3","","2190.90","412.50","9264.59","16","2703.01","4737.71","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3526.99","58","","1903.20","1903.20","3826.66","1 through 10","2703.01","4737.71","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3800.63","62.5","","2186.25","2186.25","2186.25","32","2703.01","4737.71","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4439.14","73","","5556.60","5556.60","5556.60","1 through 10","2703.01","4737.71","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","WELLPOINT [1015]","HB CH WELLPOINT","4737.71","77.91","","1955.15","885.83","3150.40","26","2703.01","4737.71","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6081.01","4560.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","3606.04","59.3","","831.03","253.22","2394.88","18","3040.51","4770.55","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6081.01","4560.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4770.55","78.45","","2481.69","1563.74","8149.28","1 through 10","3040.51","4770.55","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB CH AETNA HMO / PPO","138.17","58.3","","464.71","67.87","1012.10","221","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.17","58.3","","293.04","293.04","293.04","11","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.61","53","","983.89","983.89","983.89","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.46","58","","677.18","677.18","677.18","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.13","62.5","","46.58","46.58","46.58","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","747.15","747.15","747.15","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","1141.67","481.21","1141.67","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","76.54","76.54","76.54","1 through 10","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","WELLPOINT [1015]","HB CH WELLPOINT","184.65","77.91","","273.64","94.28","1367.51","138","105.35","184.65","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.54","59.3","","720.78","230.14","2010.94","427","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.54","59.3","","344.45","344.45","344.45","1 through 10","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","1120.13","1120.13","1120.13","1 through 10","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","456.17","105.33","1284.66","242","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","AETNA [1001]","HB CH AETNA HMO / PPO","2403.42","58.3","","464.71","67.87","1012.10","221","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2403.42","58.3","","293.04","293.04","293.04","11","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2184.93","53","","983.89","983.89","983.89","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2391.05","58","","677.18","677.18","677.18","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2576.56","62.5","","46.58","46.58","46.58","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3009.43","73","","747.15","747.15","747.15","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.45","44.45","","1141.67","481.21","1141.67","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.45","44.45","","76.54","76.54","76.54","1 through 10","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","WELLPOINT [1015]","HB CH WELLPOINT","3211.84","77.91","","273.64","94.28","1367.51","138","1832.45","3211.84","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2444.64","59.3","","720.78","230.14","2010.94","427","2061.25","3234.1","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2444.64","59.3","","344.45","344.45","344.45","1 through 10","2061.25","3234.1","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3234.10","78.45","","1120.13","1120.13","1120.13","1 through 10","2061.25","3234.1","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3234.10","78.45","","456.17","105.33","1284.66","242","2061.25","3234.1","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","464.71","67.87","1012.10","221","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","293.04","293.04","293.04","11","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","983.89","983.89","983.89","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.75","58","","677.18","677.18","677.18","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.94","62.5","","46.58","46.58","46.58","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","747.15","747.15","747.15","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","1141.67","481.21","1141.67","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","76.54","76.54","76.54","1 through 10","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","273.64","94.28","1367.51","138","1661.32","2911.89","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","720.78","230.14","2010.94","427","1868.75","2932.07","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.34","59.3","","344.45","344.45","344.45","1 through 10","1868.75","2932.07","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.75","2932.07","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","456.17","105.33","1284.66","242","1868.75","2932.07","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","AETNA [1001]","HB CH AETNA HMO / PPO","2681.80","58.3","","416.75","416.75","416.75","1 through 10","2044.7","3583.86","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.80","59.3","","7893.60","423.68","7893.60","1 through 10","2300","3608.7","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3608.70","78.45","","555.84","329.40","555.84","1 through 10","2300","3608.7","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","AETNA [1001]","HB CH AETNA HMO / PPO","2916.17","58.3","","2190.90","412.50","9264.59","16","2223.39","3897.06","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2901.16","58","","1903.20","1903.20","3826.66","1 through 10","2223.39","3897.06","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3126.25","62.5","","2186.25","2186.25","2186.25","32","2223.39","3897.06","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3651.46","73","","5556.60","5556.60","5556.60","1 through 10","2223.39","3897.06","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","WELLPOINT [1015]","HB CH WELLPOINT","3897.06","77.91","","1955.15","885.83","3150.40","26","2223.39","3897.06","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5002.00","3751.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2966.19","59.3","","831.03","253.22","2394.88","18","2501","3924.07","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5002.00","3751.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3924.07","78.45","","2481.69","1563.74","8149.28","1 through 10","2501","3924.07","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","2190.90","412.50","9264.59","16","1944.69","3408.56","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","1903.20","1903.20","3826.66","1 through 10","1944.69","3408.56","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","2186.25","2186.25","2186.25","32","1944.69","3408.56","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","5556.60","5556.60","5556.60","1 through 10","1944.69","3408.56","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1955.15","885.83","3150.40","26","1944.69","3408.56","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","831.03","253.22","2394.88","18","2187.5","3432.19","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2481.69","1563.74","8149.28","1 through 10","2187.5","3432.19","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","AETNA [1001]","HB CH AETNA HMO / PPO","1781.50","58.3","","2190.90","412.50","9264.59","16","1358.28","2380.73","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1772.34","58","","1903.20","1903.20","3826.66","1 through 10","1358.28","2380.73","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1909.84","62.5","","2186.25","2186.25","2186.25","32","1358.28","2380.73","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2230.70","73","","5556.60","5556.60","5556.60","1 through 10","1358.28","2380.73","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","WELLPOINT [1015]","HB CH WELLPOINT","2380.73","77.91","","1955.15","885.83","3150.40","26","1358.28","2380.73","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3055.75","2291.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1812.06","59.3","","831.03","253.22","2394.88","18","1527.88","2397.24","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3055.75","2291.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2397.24","78.45","","2481.69","1563.74","8149.28","1 through 10","1527.88","2397.24","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2137.67","58.3","","2190.90","412.50","9264.59","16","1629.83","2856.7","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2126.67","58","","1903.20","1903.20","3826.66","1 through 10","1629.83","2856.7","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2291.67","62.5","","2186.25","2186.25","2186.25","32","1629.83","2856.7","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2676.67","73","","5556.60","5556.60","5556.60","1 through 10","1629.83","2856.7","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","WELLPOINT [1015]","HB CH WELLPOINT","2856.70","77.91","","1955.15","885.83","3150.40","26","1629.83","2856.7","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3666.67","2750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2174.34","59.3","","831.03","253.22","2394.88","18","1833.34","2876.5","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3666.67","2750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2876.50","78.45","","2481.69","1563.74","8149.28","1 through 10","1833.34","2876.5","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","AETNA [1001]","HB CH AETNA HMO / PPO","51.62","58.3","","464.71","67.87","1012.10","221","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","51.62","58.3","","293.04","293.04","293.04","11","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.93","53","","983.89","983.89","983.89","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","51.36","58","","677.18","677.18","677.18","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","55.34","62.5","","46.58","46.58","46.58","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","64.64","73","","747.15","747.15","747.15","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.36","44.45","","1141.67","481.21","1141.67","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.36","44.45","","76.54","76.54","76.54","1 through 10","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","WELLPOINT [1015]","HB CH WELLPOINT","68.99","77.91","","273.64","94.28","1367.51","138","39.36","68.99","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.51","59.3","","720.78","230.14","2010.94","427","44.28","69.47","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","52.51","59.3","","344.45","344.45","344.45","1 through 10","44.28","69.47","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","69.47","78.45","","1120.13","1120.13","1120.13","1 through 10","44.28","69.47","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.47","78.45","","456.17","105.33","1284.66","242","44.28","69.47","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","AETNA [1001]","HB CH AETNA HMO / PPO","1461.91","58.3","","1530.90","1160.93","1884.08","89","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1329.01","53","","5253.92","5253.92","5253.92","1 through 10","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1454.38","58","","12181.47","12181.47","12181.47","1 through 10","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1567.23","62.5","","1350.68","1350.68","1350.68","1 through 10","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1114.61","44.45","","1910.74","891.94","1910.74","1 through 10","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","WELLPOINT [1015]","HB CH WELLPOINT","1953.64","77.91","","1829.79","1561.50","2617.12","88","1114.61","1953.64","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2507.56","1880.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1486.98","59.3","","1359.46","1201.30","1689.00","61","1253.78","1967.18","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2507.56","1880.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1486.98","59.3","","1718.92","1718.92","1718.92","1 through 10","1253.78","1967.18","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2507.56","1880.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1967.18","78.45","","1910.74","1019.06","2344.84","74","1253.78","1967.18","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","AETNA [1001]","HB CH AETNA HMO / PPO","2151.27","58.3","","1530.90","1160.93","1884.08","89","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1955.70","53","","5253.92","5253.92","5253.92","1 through 10","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2140.20","58","","12181.47","12181.47","12181.47","1 through 10","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2306.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1640.21","44.45","","1910.74","891.94","1910.74","1 through 10","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","WELLPOINT [1015]","HB CH WELLPOINT","2874.88","77.91","","1829.79","1561.50","2617.12","88","1640.21","2874.88","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3690.00","2767.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2188.17","59.3","","1359.46","1201.30","1689.00","61","1845","2894.81","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3690.00","2767.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2188.17","59.3","","1718.92","1718.92","1718.92","1 through 10","1845","2894.81","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3690.00","2767.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2894.81","78.45","","1910.74","1019.06","2344.84","74","1845","2894.81","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","AETNA [1001]","HB CH AETNA HMO / PPO","2915.82","58.3","","1530.90","1160.93","1884.08","89","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.74","53","","5253.92","5253.92","5253.92","1 through 10","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2900.81","58","","12181.47","12181.47","12181.47","1 through 10","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3125.88","62.5","","1350.68","1350.68","1350.68","1 through 10","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2223.12","44.45","","1910.74","891.94","1910.74","1 through 10","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","WELLPOINT [1015]","HB CH WELLPOINT","3896.59","77.91","","1829.79","1561.50","2617.12","88","2223.12","3896.59","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5001.40","3751.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.83","59.3","","1359.46","1201.30","1689.00","61","2500.7","3923.6","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5001.40","3751.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2965.83","59.3","","1718.92","1718.92","1718.92","1 through 10","2500.7","3923.6","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5001.40","3751.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3923.60","78.45","","1910.74","1019.06","2344.84","74","2500.7","3923.6","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","469.25","1877.00","1 through 10","502.36","912.33","per diem",""
"Impltj Biologic Implnt St Rnfcmtn|BILATERAL PROCEDURE","PX-76000197","CDM","15777","CPT","0761","RC","","","50","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","4223.26","703.88","4223.26","1 through 10","","","per diem",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","617.00","462.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","407.00","14","193.33","768.52","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","365.88","59.3","","351.60","351.60","351.60","1 through 10","204.8","489.19","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","273.36","273.36","461.28","1 through 10","204.8","489.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","617.00","462.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","101.75","407.00","14","193.33","768.52","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","365.88","59.3","","351.60","351.60","351.60","1 through 10","204.8","489.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","273.36","273.36","461.28","1 through 10","204.8","489.19","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","252.40","252.40","252.40","1 through 10","285","447.17","percent of total billed charges",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","","","","inpatient","","","19743.06","14807.29","MEDICARE [2001]","HB NWH MEDICARE","13547.21","","Case rate ($13,547.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,656.98, add-ons for qualifying new technology services are included. If operating cost exceeds $57,799.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,883.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,605.66. The transfer operating threshold is the transfer adjustment factor * $12,656.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.56. The transfer capital threshold is the transfer adjustment factor * $941.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","920.28","920.28","920.28","1 through 10","12074.55","14597.86","other","Inpatient DRG"
"Inborn Errors Of Metabolism,MAJOR","423","DRG","","","","","","","","inpatient","","","69240.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25167.10","","Standard inlier is a Case rate ($25,167.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,467, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,572.57) for the length of stay and the standard reimbursement.","25167.09","25167.09","25167.09","1 through 10","6930.73","59767.48","case rate",""
"Inborn Errors Of Metabolism,MAJOR","423","DRG","","","","","","","","inpatient","","","69240.55","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","25745.50","","Case rate ($27,736.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $70,166.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27808.04","27808.04","27808.04","1 through 10","6930.73","59767.48","case rate",""
"Inborn Errors Of Metabolism,MINOR","423","DRG","","","","","","","","inpatient","","","9982.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13138.03","","Standard inlier is a Case rate ($13,138.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,195, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,864.89) for the length of stay and the standard reimbursement.","13138.03","13138.03","13138.03","1 through 10","6930.73","59767.48","case rate",""
"Incision/Remove FB Subq Complex","PX-76000009","CDM","10121","CPT","0761","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1216.22","2208.75","per diem",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","657.00","492.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","259.68","259.68","1 through 10","281.85","567.68","other","ASC "
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","657.00","492.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","738.09","738.09","738.09","1 through 10","281.85","567.68","other","Multiple Surgery"
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.55","3.41","AETNA [1001]","HB CH AETNA HMO / PPO","2.65","58.3","","4.29","4.29","4.29","1 through 10","2.02","6.97","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.55","3.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","2.38","52.2","","3.89","3.89","3.89","1 through 10","2.28","3.57","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.55","3.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3.57","78.45","","5.38","5.31","5.38","1 through 10","2.28","3.57","percent of total billed charges",""
"Inf Nucleic Acid Virus 12-25 Target","PX-30001404","CDM","87633","CPT","0306","RC","","","","both","","","3270.00","2452.50","AETNA [1001]","HB CH AETNA HMO / PPO","1906.41","58.3","","1189.00","1189.00","1189.00","1 through 10","408.44","3106.5","percent of total billed charges",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","34618.17","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","19122.06","","Case rate ($20,601.01). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,031.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20653.98","20653.98","20653.98","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16910.45","","Standard inlier is a Case rate ($16,910.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,997, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,400.50) for the length of stay and the standard reimbursement.","16144.56","16144.56","16144.56","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18165.19","","Standard inlier is a Case rate ($18,165.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,997, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,578.47) for the length of stay and the standard reimbursement.","17339.50","13871.60","18165.19","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13679.4","","Fee schedule rate ($13,003.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.4","15297.48","15297.48","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7234.4484","","Fee schedule rate ($13,003.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7234.4484","15297.48","15297.48","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","MASSHEALTH [3001]","HB NWH MEDICAID","8563.18","","Case rate ($9,225.47). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,655.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9249.19","9249.19","9249.19","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","20513.02","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","8563.18","","Case rate ($9,225.47). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,655.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","7864.41","","Standard inlier is a Case rate ($7,864.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $19,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,116.38) for the length of stay and the standard reimbursement.","7864.41","7864.41","7864.41","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8447.95","","Standard inlier is a Case rate ($8,447.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $19,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,199.15) for the length of stay and the standard reimbursement.","8063.94","8063.94","8447.94","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13679.4","","Per diem ($3,617). If length of stay < 2, first 1 days paid at a per diem of $7,234 instead.","13679.4","7234.44","7234.44","1 through 10","2033","63939.85","per diem","Estimated amount calculated based on 1 day length of stay."
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7234.4484","","Per diem ($3,617). If length of stay < 2, first 1 days paid at a per diem of $7,234 instead.","7234.4484","7234.44","7234.44","1 through 10","2033","63939.85","per diem","Estimated amount calculated based on 1 day length of stay."
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","MASSHEALTH [3001]","HB NWH MEDICAID","3270.59","","Case rate ($3,523.55). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,953.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,329.64 and the sum of the standard inlier and any outlier amount.","4415.76","4415.76","4415.76","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","10965.65","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3270.59","","Case rate ($3,523.55). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,953.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,329.64 and the sum of the standard inlier and any outlier amount.","4415.76","4415.76","4415.76","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11605.40","","Standard inlier is a Case rate ($11,605.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,555, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,647.43) for the length of stay and the standard reimbursement.","11605.40","11605.40","11605.40","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12466.52","","Standard inlier is a Case rate ($12,466.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,555, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,769.57) for the length of stay and the standard reimbursement.","11899.85","11899.85","12466.51","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13679.4","","Fee schedule rate ($19,104.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.4","9313.72","9313.72","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7234.4484","","Fee schedule rate ($19,104.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7234.4484","9313.72","9313.72","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","MASSHEALTH [3001]","HB NWH MEDICAID","4909.89","","Case rate ($5,289.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,719.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5003.05","5003.05","5003.05","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","4919.79","","Fee schedule rate ($4,919.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4919.76","4919.76","4919.76","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12336.73","","Fee schedule rate ($12,336.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12336.73","12336.73","12336.73","1 through 10","2033","63939.85","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16346.51","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4909.89","","Case rate ($5,289.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,719.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5303.23","5303.23","6629.04","1 through 10","2033","63939.85","case rate",""
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","both","","","2627.00","1970.25","AETNA [1001]","HB CH AETNA HMO / PPO","1531.54","58.3","","1448.12","1448.12","1448.12","1 through 10","408.44","2495.65","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza Ea Type","PX-30001284","CDM","87501","CPT","0306","RC","","","","both","","","366.00","274.50","AETNA [1001]","HB CH AETNA HMO / PPO","213.38","58.3","","201.85","201.85","201.85","1 through 10","50.28","347.7","percent of total billed charges",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","87480.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","115032.18","","Fee schedule rate ($115,032.18). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($13,309.91) multiplied by length of stay and the outlier percent (100%).","109803.44","109803.44","109803.44","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","78910.73","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","58066.23","","Standard inlier is a Case rate ($58,066.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $71,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,242.73) for the length of stay and the standard reimbursement.","58066.22","58066.22","58066.22","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","78910.73","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","62374.71","","Standard inlier is a Case rate ($62,374.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $71,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,853.83) for the length of stay and the standard reimbursement.","59539.49","59539.49","62374.71","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","78910.73","","MASSHEALTH [3001]","HB NWH MEDICAID","20367.24","","Case rate ($21,942.49). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $64,372.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21998.92","21998.92","21998.92","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","78910.73","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","20367.24","","Case rate ($21,942.49). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $64,372.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16515.70","16515.70","16736.93","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MODERATE","710","DRG","","","","","","","","inpatient","","","33303.49","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35441.34","","Standard inlier is a Case rate ($35,441.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,031.04) for the length of stay and the standard reimbursement.","3914.95","3914.95","3914.95","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MODERATE","710","DRG","","","","","","","","inpatient","","","33303.49","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38071.06","","Standard inlier is a Case rate ($38,071.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,404.03) for the length of stay and the standard reimbursement.","38071.06","38071.06","38071.06","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","31679.14","23759.35","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","19034.31","","Case rate ($19,034.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,783.50, add-ons for qualifying new technology services are included. If operating cost exceeds $62,925.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,264.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,711.39. The transfer operating threshold is the transfer adjustment factor * $17,783.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.92. The transfer capital threshold is the transfer adjustment factor * $1,322.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17230.56","17230.56","17230.56","1 through 10","16965.16","19759.2109","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","31679.14","23759.35","MEDICARE [2001]","HB NWH MEDICARE","19034.31","","Case rate ($19,034.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,783.50, add-ons for qualifying new technology services are included. If operating cost exceeds $62,925.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,264.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $17,711.39. The transfer operating threshold is the transfer adjustment factor * $17,783.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.92. The transfer capital threshold is the transfer adjustment factor * $1,322.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19070.22","11462.69","19104.50","17","16965.16","19759.2109","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","80225.46","60169.09","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","44071.29","","Case rate ($42,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,954.55, add-ons for qualifying new technology services are included. If operating cost exceeds $89,096.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,211.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $39,517.88. The transfer operating threshold is the transfer adjustment factor * $43,954.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,269.79. The transfer capital threshold is the transfer adjustment factor * $3,269.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","44785.83","44785.83","44785.83","1 through 10","41931.91","50694.73","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","80225.46","60169.09","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","42787.66","","Case rate ($42,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,954.55, add-ons for qualifying new technology services are included. If operating cost exceeds $89,096.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,211.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $39,517.88. The transfer operating threshold is the transfer adjustment factor * $43,954.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,269.79. The transfer capital threshold is the transfer adjustment factor * $3,269.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16919.85","16919.85","16919.85","1 through 10","41931.91","50694.73","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","80225.46","60169.09","MEDICARE [2001]","HB NWH MEDICARE","42787.66","","Case rate ($42,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,954.55, add-ons for qualifying new technology services are included. If operating cost exceeds $89,096.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,211.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $39,517.88. The transfer operating threshold is the transfer adjustment factor * $43,954.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,269.79. The transfer capital threshold is the transfer adjustment factor * $3,269.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","47733.27","24859.48","47819.07","27","41931.91","50694.73","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","80225.46","60169.09","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","41931.91","","Case rate ($42,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,954.55, add-ons for qualifying new technology services are included. If operating cost exceeds $89,096.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,211.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $39,517.88. The transfer operating threshold is the transfer adjustment factor * $43,954.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,269.79. The transfer capital threshold is the transfer adjustment factor * $3,269.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42643.65","42643.65","42643.65","1 through 10","41931.91","50694.73","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","80225.46","60169.09","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","41931.91","","Case rate ($42,787.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $43,954.55, add-ons for qualifying new technology services are included. If operating cost exceeds $89,096.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,211.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $39,517.88. The transfer operating threshold is the transfer adjustment factor * $43,954.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,269.79. The transfer capital threshold is the transfer adjustment factor * $3,269.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42677.16","42677.16","42677.16","1 through 10","41931.91","50694.73","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System With McC","727","MS-DRG","","","","","","","","inpatient","","","29938.49","22453.87","MEDICARE [2001]","HB NWH MEDICARE","14126.40","","Case rate ($14,126.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,198.11, add-ons for qualifying new technology services are included. If operating cost exceeds $58,340.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,923.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,144.60. The transfer operating threshold is the transfer adjustment factor * $13,198.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.81. The transfer capital threshold is the transfer adjustment factor * $981.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14024.20","14024.20","14024.20","1 through 10","12590.78","14530.8966","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","22118.85","16589.14","MEDICARE [2001]","HB NWH MEDICARE","7028.18","","Case rate ($7,028.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,219.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,362.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,479.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,491.09. The transfer operating threshold is the transfer adjustment factor * $7,219.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.09. The transfer capital threshold is the transfer adjustment factor * $537.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7812.58","7798.55","7812.58","1 through 10","6887.62","8080.3019","other","Inpatient Replacement Plans DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","22118.85","16589.14","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6887.62","","Case rate ($7,028.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,219.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,362.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,479.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,491.09. The transfer operating threshold is the transfer adjustment factor * $7,219.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.09. The transfer capital threshold is the transfer adjustment factor * $537.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6986.90","6986.90","6986.90","1 through 10","6887.62","8080.3019","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","24754.17","18565.63","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8458.59","","Case rate ($8,458.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,689.27, add-ons for qualifying new technology services are included. If operating cost exceeds $53,831.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,812.19. The transfer operating threshold is the transfer adjustment factor * $8,689.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.40. The transfer capital threshold is the transfer adjustment factor * $646.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9337.78","9337.78","9337.78","1 through 10","8289.42","9814.8325","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","24754.17","18565.63","MEDICARE [2001]","HB NWH MEDICARE","8458.59","","Case rate ($8,458.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,689.27, add-ons for qualifying new technology services are included. If operating cost exceeds $53,831.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,812.19. The transfer operating threshold is the transfer adjustment factor * $8,689.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.40. The transfer capital threshold is the transfer adjustment factor * $646.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9472.58","9472.46","9489.61","1 through 10","8289.42","9814.8325","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","24754.17","18565.63","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8289.42","","Case rate ($8,458.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,689.27, add-ons for qualifying new technology services are included. If operating cost exceeds $53,831.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,812.19. The transfer operating threshold is the transfer adjustment factor * $8,689.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.40. The transfer capital threshold is the transfer adjustment factor * $646.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8497.87","8497.87","8497.87","1 through 10","8289.42","9814.8325","other","Inpatient DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","37243.01","27932.26","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13708.93","","Case rate ($13,708.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,082.79, add-ons for qualifying new technology services are included. If operating cost exceeds $59,225.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,989.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,661.31. The transfer operating threshold is the transfer adjustment factor * $14,082.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.62. The transfer capital threshold is the transfer adjustment factor * $1,047.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14011.40","14011.40","14011.40","1 through 10","13434.75","16067.6472","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","37243.01","27932.26","MEDICARE [2001]","HB NWH MEDICARE","13708.93","","Case rate ($13,708.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,082.79, add-ons for qualifying new technology services are included. If operating cost exceeds $59,225.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,989.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,661.31. The transfer operating threshold is the transfer adjustment factor * $14,082.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.62. The transfer capital threshold is the transfer adjustment factor * $1,047.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15535.25","15535.25","15535.25","1 through 10","13434.75","16067.6472","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","21658.35","16243.76","MEDICARE [2001]","HB NWH MEDICARE","6490.20","","Case rate ($6,490.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,063.71, add-ons for qualifying new technology services are included. If operating cost exceeds $51,205.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,393.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,039.12. The transfer operating threshold is the transfer adjustment factor * $6,063.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $451.08. The transfer capital threshold is the transfer adjustment factor * $451.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6397.47","6397.47","6408.97","1 through 10","5784.68","6628.5967","other","Inpatient DRG"
"Inflammatory Bowel Disease,EXTREME","245","DRG","","","","","","","","inpatient","","","46333.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","42788.48","","Standard inlier is a Case rate ($42,788.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $55,545, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,073.99) for the length of stay and the standard reimbursement.","42788.48","42788.48","42788.48","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,EXTREME","245","DRG","","","","","","","","inpatient","","","46333.99","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13561.0071","","Fee schedule rate ($50,827.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13561.0071","50827.60","50827.60","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","28960.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26305.03","","Standard inlier is a Case rate ($26,305.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,733.89) for the length of stay and the standard reimbursement.","25109.34","25109.34","25109.34","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","28960.51","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12915.3078","","Fee schedule rate ($25,771.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12915.3078","25771.98","25771.98","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","28960.51","","MASSHEALTH [3001]","HB NWH MEDICAID","12747.66","","Case rate ($13,733.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,163.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17211.14","17211.14","17211.14","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","28960.51","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","10785.39","","Fee schedule rate ($10,785.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10785.31","10785.31","10785.31","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","17707.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13385.19","","Standard inlier is a Case rate ($13,385.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,900.08) for the length of stay and the standard reimbursement.","13724.80","13724.80","13724.80","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","17707.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14378.36","","Standard inlier is a Case rate ($14,378.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,040.95) for the length of stay and the standard reimbursement.","14378.36","14378.36","14378.36","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","17707.32","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12915.3078","","Fee schedule rate ($12,915.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12915.3078","12915.30","12915.30","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","21644.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13385.19","","Standard inlier is a Case rate ($13,385.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,900.08) for the length of stay and the standard reimbursement.","16294.11","16294.11","16294.11","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","21644.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14378.36","","Standard inlier is a Case rate ($14,378.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,040.95) for the length of stay and the standard reimbursement.","17502.89","2121.62","18336.36","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","21644.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12915.3078","","Fee schedule rate ($15,916.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12915.3078","15916.96","15916.96","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","21644.77","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","17508.49","","Fee schedule rate ($17,508.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17508.49","17508.49","17508.49","1 through 10","6022.55","79871.61","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","21644.77","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","15661.76","","Fee schedule rate ($15,661.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19562.14","19562.14","19562.14","1 through 10","6022.55","79871.61","case rate",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","46809.82","35107.36","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13208.15","","Case rate ($13,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,568.36, add-ons for qualifying new technology services are included. If operating cost exceeds $58,710.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,198.80. The transfer operating threshold is the transfer adjustment factor * $13,568.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.35. The transfer capital threshold is the transfer adjustment factor * $1,009.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12974.00","12974.00","12974.00","1 through 10","12943.99","14878.0005","other","Inpatient Replacement Plans DRG"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","46809.82","35107.36","MEDICARE [2001]","HB NWH MEDICARE","13208.15","","Case rate ($13,208.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,568.36, add-ons for qualifying new technology services are included. If operating cost exceeds $58,710.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,951.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,198.80. The transfer operating threshold is the transfer adjustment factor * $13,568.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,009.35. The transfer capital threshold is the transfer adjustment factor * $1,009.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14359.21","4191.97","14385.02","1 through 10","12943.99","14878.0005","other","Inpatient Replacement Plans DRG"
"Inguinal, Femoral And Umbilical Hernia Procedures,MINOR","228","DRG","","","","","","","","inpatient","","","24136.30","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13675.4916","","Fee schedule rate ($13,675.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13675.4916","19012.42","19012.42","1 through 10","6697.69","38063.16","case rate",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","both","","","128.00","96.00","AETNA [1001]","HB CH AETNA HMO / PPO","74.62","58.3","","70.31","70.31","70.31","1 through 10","15.28","121.6","percent of total billed charges",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","outpatient","","","128.00","96.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","75.90","59.3","","72.66","72.66","72.66","1 through 10","16.07","100.42","percent of total billed charges",""
"Inj Anes Ilioinguinal/Hypogastric","PX-76001508","CDM","64425","CPT","0761","RC","","","","both","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.61","807.61","807.61","1 through 10","528.96","868.7","other","OPPS APC"
"Inj Anes Ilioinguinal/Hypogastric|BILATERAL PROCEDURE","PX-76001508","CDM","64425","CPT","0761","RC","","","50","both","","","1190.00","892.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1273.57","1273.57","1273.57","1 through 10","781.29","3494.06","other","OPPS APC"
"Inj Anes Ilioinguinal/Hypogastric|BILATERAL PROCEDURE","PX-76001508","CDM","64425","CPT","0761","RC","","","50","outpatient","","","1190.00","892.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1027.16","","Case rate ($1,027.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1452.40","1452.40","1452.40","1 through 10","1027.16","2218.59","other","ASC "
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","825.00","618.75","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","784.58","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","825.00","618.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","413.33","50.1","","2255.00","204.62","2255.00","1 through 10","366.71","647.21","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1733.64","1733.64","1733.64","1 through 10","366.71","647.21","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1182.00","886.50","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1124.08","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1182.00","886.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","592.18","50.1","","2255.00","204.62","2255.00","1 through 10","525.4","927.28","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1182.00","886.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","927.28","78.45","","1733.64","1733.64","1733.64","1 through 10","525.4","927.28","percent of total billed charges",""
"Inj Bupivicaine Hcl per 30 Ml","PX-63601266","CDM","S0020","HCPCS","0636","RC","","","","outpatient","","","2.70","2.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1.60","59.3","","9.89","5.18","9.89","1 through 10","1.08","2.12","percent of total billed charges",""
"Inj Cntr W/Fluor Evl G/D/J/G-J/C TB","PX-75000306","CDM","49465","CPT","0761","RC","","","","both","","","355.00","266.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","152.3","896.88","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2252.00","1689.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1040.36","1036.13","1561.70","1 through 10","764.84","1643.96","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1897.09","1897.09","1897.09","1 through 10","1311.96","4373.87","other","ASC "
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2251.00","1688.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1560.54","1043.63","1562.90","1 through 10","764.84","1643.23","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1636.90","1536.98","1636.90","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MEDICARE [2001]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1585.91","1585.91","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,553). Procedure 2, Per diem ($1,276.50). Procedures 3 - 9999, Per diem ($638.25).","2553.00","2553.00","2553.00","1 through 10","1004.41","4462.84","per diem",""
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","2815.50","2815.50","2815.50","1 through 10","1004.41","4462.84","per diem",""
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1477.73","1477.73","1561.99","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.70","1561.70","1561.70","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2251.00","1688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1855.11","1855.11","1894.47","15","1311.96","4373.87","other","ASC "
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2251.00","1688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1857.74","1857.74","1897.09","12","1311.96","4373.87","other","ASC "
"Inj Paravert F Jnt L/S 2 Lev|BILATERAL PROCEDURE","PX-76001544","CDM","64494","CPT","0761","RC","","","50","both","","","270.00","202.50","","","","","","1276.50","1276.50","1276.50","1 through 10","","","",""
"Inj Paravert F Jnt L/S 2 Lev|BILATERAL PROCEDURE","PX-76001544","CDM","64494","CPT","0761","RC","","","50","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","1407.75","1407.75","1407.75","1 through 10","","","per diem",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","460.00","345.00","WELLPOINT [1015]","HB CH WELLPOINT","358.39","77.91","","345.81","345.81","345.81","1 through 10","74.36","358.39","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","754.00","565.50","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.89","76.89","76.89","1 through 10","80.29","587.44","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","356.00","267.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","188.68","361.04","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","356.00","267.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","178.36","50.1","","2255.00","204.62","2255.00","1 through 10","158.24","567.68","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","279.28","78.45","","1733.64","1733.64","1733.64","1 through 10","158.24","567.68","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","523.23","475.20","523.23","1 through 10","247.48","868.7","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1190.00","892.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","475.19","515.32","1 through 10","333.03","1444.05","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1190.00","892.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","600.27","600.27","613.01","1 through 10","424.52","1804.32","other","ASC "
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1190.00","892.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","601.12","306.93","613.86","20","424.52","1804.32","other","ASC "
"Inject Anes Nerve Intercostal Multi","PX-76001507","CDM","64421","CPT","0761","RC","","","","both","","","2170.00","1627.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1036.13","1036.13","1036.13","1 through 10","764.84","1584.1","other","OPPS APC"
"Inject Anes Nerve Intercostal Sgl","PX-76001506","CDM","64420","CPT","0761","RC","","","","both","","","1182.00","886.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2015.21","2015.21","2015.21","1 through 10","598.81","1699.09","other","Multiple Surgery"
"Inject Anes Nerve Intercostal Sgl","PX-76001506","CDM","64420","CPT","0761","RC","","","","both","","","1182.00","886.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","402.99","402.99","402.99","1 through 10","598.81","1699.09","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1189.00","891.75","AETNA [1001]","HB CH AETNA HMO / PPO","693.19","58.3","","655.45","655.45","655.45","1 through 10","598.81","867.97","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1189.00","891.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1776.71","1776.71","1776.71","1 through 10","598.81","867.97","other","Multiple Surgery"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","969.63","969.63","969.63","1 through 10","528.51","970.06","other","ASC "
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1425.17","1425.17","1425.17","1 through 10","528.51","970.06","other","Multiple Surgery"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","932.77","78.45","","888.73","888.73","888.73","1 through 10","528.51","970.06","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","1189.00","891.75","MARTIN'S POINT [160007]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1209.85","1209.85","1209.85","1 through 10","510.08","3494.06","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","1189.00","891.75","TRICARE [160005]","HB NWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1233.61","1233.61","1233.61","1 through 10","510.08","3494.06","other","Tricare OPPS"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","outpatient","","","1189.00","891.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1027.16","","Case rate ($1,027.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1452.40","1452.40","1452.40","1 through 10","1027.16","2218.59","other","ASC "
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","outpatient","","","1189.00","891.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1027.16","","Case rate ($1,027.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1485.27","1454.46","1485.27","16","1027.16","2218.59","other","ASC "
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","682.82","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.72","50.1","","2255.00","204.62","2255.00","1 through 10","319.15","567.68","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","563.27","78.45","","1733.64","1733.64","1733.64","1 through 10","319.15","567.68","percent of total billed charges",""
"Inject Anes Nerve Pudendal","PX-76001509","CDM","64430","CPT","0761","RC","","","","both","","","2252.00","1689.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2971.41","2856.68","2971.41","1 through 10","609.18","2140.42","other","Multiple Surgery"
"Inject Anes Nerve Pudendal","PX-76001509","CDM","64430","CPT","0761","RC","","","","both","","","2252.00","1689.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1560.30","1557.37","1561.70","1 through 10","609.18","2140.42","other","OPPS APC"
"Inject Anes Nerve Pudendal","PX-76001509","CDM","64430","CPT","0761","RC","","","","outpatient","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1238.49","1238.49","1238.49","1 through 10","764.84","1873.9","other","ASC "
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1468.33","1560.54","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2252.00","1689.00","FALLON HEALTH [1008]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4757.73","4757.73","4757.73","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2252.00","1689.00","MARTIN'S POINT [160007]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1555.09","1470.38","1555.09","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2252.00","1689.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.99","1560.54","1561.99","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2252.00","1689.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1554.19","1554.19","1554.19","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","outpatient","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1894.47","1855.11","1894.47","13","1311.96","3485.45","other","ASC "
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","outpatient","","","2252.00","1689.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1897.09","1857.74","1897.09","51","1311.96","3485.45","other","ASC "
"Inject Anes Nerve Trigeminal|BILATERAL PROCEDURE","PX-76001497","CDM","64400","CPT","0761","RC","","","50","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","306.93","306.93","306.93","1 through 10","424.52","1804.32","other","ASC "
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","364.65","364.65","364.65","1 through 10","173.31","847","per diem",""
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","outpatient","","","327.00","245.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.91","59.3","","186.35","186.35","186.35","1 through 10","140.26","598.81","percent of total billed charges",""
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","outpatient","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.53","78.45","","244.48","244.48","244.48","1 through 10","140.26","598.81","percent of total billed charges",""
"Inject Arthrogram Sacroiliac Joint|BILATERAL PROCEDURE","PX-76001795","CDM","27096","CPT","0761","RC","","","50","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","698.88","698.58","699.13","1 through 10","140.28","3494.06","per diem",""
"Inject Arthrogram Sacroiliac Joint|BILATERAL PROCEDURE","PX-76001795","CDM","27096","CPT","0761","RC","","","50","outpatient","","","327.00","245.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","210.39","","Case rate ($210.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","297.49","297.49","303.80","1 through 10","210.39","2218.59","other","ASC "
"Inject Arthrogram Sacroiliac Joint|BILATERAL PROCEDURE","PX-76001795","CDM","27096","CPT","0761","RC","","","50","outpatient","","","327.00","245.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","210.39","","Case rate ($210.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","304.22","297.91","304.22","12","210.39","2218.59","other","ASC "
"Inject Carpal Tunnel Therapeutic","PX-76000285","CDM","20526","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","473.26","473.26","473.26","1 through 10","247.48","529.79","percent of total billed charges",""
"Inject Carpal Tunnel Therapeutic","PX-76000285","CDM","20526","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","640.97","640.97","1 through 10","247.48","529.79","other","Multiple Surgery"
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","126.72","126.72","126.72","1 through 10","90.68","158.94","per diem",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","204.00","153.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.97","59.3","","116.03","116.03","116.03","1 through 10","64.13","160.04","percent of total billed charges",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.04","78.45","","1145.08","152.22","1145.08","1 through 10","64.13","160.04","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","119.78","176.08","per diem",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","outpatient","","","226.00","169.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","177.30","78.45","","169.13","169.13","169.13","1 through 10","75.24","177.3","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","969.63","495.09","990.18","1 through 10","598.81","1873.9","other","ASC "
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1479.06","1479.06","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1408.96","78.45","","795.48","795.48","795.48","1 through 10","598.81","1873.9","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","281.00","210.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","145.89","145.89","145.89","1 through 10","140.5","283.83","other","ASC "
"Inject Sentinel Node ID|BILATERAL PROCEDURE","PX-76001212","CDM","38792","CPT","0761","RC","","","50","outpatient","","","1124.00","843.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","606.36","","Case rate ($606.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","429.31","429.30","429.31","1 through 10","606.36","1522.84","other","ASC "
"Inject Shoulder Arthrogram","PX-76000386","CDM","23350","CPT","0761","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","355.24","355.24","355.24","1 through 10","85.85","202.4","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","247.48","529.79","per diem",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","323.26","171.78","344.25","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","374.79","1 through 10","247.48","529.79","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","640.97","640.97","1 through 10","247.48","529.79","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","262.00","270.00","1 through 10","247.48","529.79","per diem",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","TRICARE [160005]","HB NWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","350.56","350.56","350.56","1 through 10","247.48","529.79","other","Tricare OPPS"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","200.09","408.67","1 through 10","247.48","567.68","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","200.37","409.23","17","247.48","567.68","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","387.35","387.35","387.35","1 through 10","247.48","567.68","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","611.28","611.28","667.11","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","533.46","78.45","","508.18","301.15","508.18","1 through 10","247.48","567.68","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","3384.99","15","247.48","529.79","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","332.63","361.53","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","616.23","640.97","1 through 10","247.48","529.79","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","496.40","73","","4358.10","4358.10","4358.10","1 through 10","247.48","529.79","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","161.63","2813.50","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","247.48","529.79","per diem",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($256). Procedure 2, Per diem ($128). Procedures 3 - 9999, Per diem ($64).","243.00","243.00","243.00","1 through 10","247.48","529.79","per diem",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","262.00","270.00","33","247.48","529.79","per diem",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","247.48","529.79","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.96","343.55","350.56","19","247.48","529.79","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","520.60","13","247.48","529.79","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","204.34","408.67","47","247.48","567.68","other","ASC "
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","400.74","409.23","107","247.48","567.68","other","ASC "
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","1609.32","387.35","1936.75","16","247.48","567.68","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","28","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","611.28","589.00","640.97","18","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","589.00","589.00","589.00","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","533.46","78.45","","508.18","301.15","508.18","12","247.48","567.68","percent of total billed charges",""
"Inject Wrist Arthrogram","PX-76000442","CDM","25246","CPT","0761","RC","","","","outpatient","","","313.00","234.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","245.55","78.45","","104.84","104.84","104.84","1 through 10","126.25","245.55","percent of total billed charges",""
"Injection Aa&/Strd Genicular Nrv Branches W/Img","PX-76002664","CDM","64454","CPT","0761","RC","","","","both","","","1132.00","849.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.47","813.47","813.47","1 through 10","598.81","2093.92","other","OPPS APC"
"Injection Aa&/Strd Genicular Nrv Branches W/Img","PX-98301900","CDM","64454","CPT","0983","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.47","813.47","813.47","1 through 10","225.78","2093.92","other","OPPS APC"
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","both","","","1222.00","916.50","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1162.12","other","OPPS APC"
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","612.22","50.1","","2255.00","204.62","2255.00","1 through 10","543.18","958.66","percent of total billed charges",""
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","958.66","78.45","","1733.64","1733.64","1733.64","1 through 10","543.18","958.66","percent of total billed charges",""
"Injection Anesthetic Agent Pudendal Nerve","PX-98301703","CDM","64430","CPT","0983","RC","","","","both","","","567.00","425.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2971.41","2856.68","2971.41","1 through 10","300.51","2140.42","other","Multiple Surgery"
"Injection Anesthetic Agent Pudendal Nerve","PX-98301703","CDM","64430","CPT","0983","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1560.30","1557.37","1561.70","1 through 10","300.51","2140.42","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1468.33","1560.54","1 through 10","1004.41","4462.84","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","FALLON HEALTH [1008]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4757.73","4757.73","4757.73","1 through 10","1004.41","4462.84","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","MARTIN'S POINT [160007]","HB NWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1555.09","1470.38","1555.09","1 through 10","1004.41","4462.84","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.99","1560.54","1561.99","1 through 10","1004.41","4462.84","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1554.19","1554.19","1554.19","1 through 10","1004.41","4462.84","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1226.00","919.50","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1165.93","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1226.00","919.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","614.23","50.1","","2255.00","204.62","2255.00","1 through 10","544.96","961.8","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1226.00","919.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","961.80","78.45","","1733.64","1733.64","1733.64","1 through 10","544.96","961.8","percent of total billed charges",""
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","21.84","16.38","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6.59","","APC Price ($6.73). Final payment is multiplied by 98%.","6.24","6.24","6.24","400","6.39","21.27","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","125.31","125.31","125.31","71","48.01","232.43","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","43.67","43.67","87.33","36","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","41.59","83.17","144","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","FALLON HEALTH [1008]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","HUMANA [1012]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.90","82.90","82.90","1 through 10","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42.26","42.26","84.52","1435","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.42","82.83","133","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.01","44.45","","100.69","100.69","100.69","11","48.01","232.43","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","42.26","84.52","38","48.01","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","129.51","129.51","129.51","63","54","204.65","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","169.90","100.69","169.91","19","54","204.65","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","AETNA [1001]","HB CH AETNA HMO / PPO","14.90","58.3","","0.01","0.01","0.01","1 through 10","6.18","20.87","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.37","6.37","6.37","100","6.18","20.87","other","OPPS APC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","12907.00","9680.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11468.03","11468.03","11468.03","1 through 10","5737.16","12799.76","other","OPPS APC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","12907.00","9680.25","MEDICARE [2001]","HB NWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34963.50","34963.50","34963.50","1 through 10","5737.16","12799.76","other","OPPS APC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","12907.00","9680.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","5761.00","5761.00","5761.00","1 through 10","5737.16","12799.76","per diem",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","outpatient","","","12907.00","9680.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","7653.85","59.3","","7354.89","7354.89","7354.89","1 through 10","6421.57","20833.55","percent of total billed charges",""
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","both","","","8077.00","6057.75","MEDICARE [2001]","HB NWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6419.59","6419.59","6419.59","1 through 10","3938.87","13146.34","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","14577.00","10932.75","MEDICARE [2001]","HB NWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71813.64","71813.64","71813.64","1 through 10","6253.53","102266.15","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3737.85","3737.85","3737.85","1 through 10","1093.63","3849.59","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","2730.00","2047.50","AETNA [1001]","HB CH AETNA HMO / PPO","1591.59","58.3","","1505.39","1505.39","1505.39","1 through 10","1093.63","2126.94","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","1093.63","2126.94","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","2730.00","2047.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2832.50","2832.50","2832.50","1 through 10","1093.63","2126.94","other","Multiple Surgery"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","2730.00","2047.50","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5558.53","1747.95","5558.53","1 through 10","1093.63","2126.94","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1805.91","1805.91","1805.91","1 through 10","1093.63","4472.66","other","ASC "
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1808.41","1770.89","1808.41","1 through 10","1093.63","4472.66","other","ASC "
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","2730.00","2047.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3215.27","3215.27","3215.27","1 through 10","1093.63","4472.66","other","Multiple Surgery"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","outpatient","","","7309.00","5481.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4873.64","4873.64","4873.64","1 through 10","2652.59","5733.91","other","ASC "
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","5551.00","4163.25","AETNA [1001]","HB CH AETNA HMO / PPO","3236.23","58.3","","6121.34","3060.67","6121.34","1 through 10","2377.37","4324.78","percent of total billed charges",""
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","5551.00","4163.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5919.65","4443.33","6157.39","1 through 10","2377.37","4324.78","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","5551.00","4163.25","MEDICARE [2001]","HB NWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2377.37","4324.78","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","5551.00","4163.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3665.10","3416.32","3678.05","1 through 10","2377.37","4324.78","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","5551.00","4163.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6727.96","5372.86","6989.47","1 through 10","2377.37","4472.66","other","Multiple Surgery"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1335.02","2906.42","other","OPPS APC"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3228.00","2421.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3228.00","2421.00","MEDICARE [2001]","HB NWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4435.65","2207.74","4435.65","1 through 10","1335.02","2906.42","other","OPPS APC"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","outpatient","","","3228.00","2421.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2398.57","2449.46","1 through 10","1335.02","2532.37","other","ASC "
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","outpatient","","","3228.00","2421.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","1200.98","2452.85","1 through 10","1335.02","2532.37","other","ASC "
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","outpatient","","","3228.00","2421.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3297.50","3297.50","3297.50","1 through 10","1335.02","2532.37","other","Multiple Surgery"
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","AETNA [1001]","HB CH AETNA HMO / PPO","149.25","58.3","","2343.98","141.18","4949.91","1 through 10","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","148.48","58","","1507.43","125.75","1624.08","1 through 10","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","148.48","58","","1817.94","1773.09","2455.60","1 through 10","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","160.00","62.5","","1910.40","159.36","4116.48","15","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.79","44.45","","6711.63","6711.63","6711.63","1 through 10","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","WELLPOINT [1015]","HB CH WELLPOINT","199.45","77.91","","4701.97","2773.92","12305.46","1 through 10","113.79","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","129.87","127.18","129.87","43","89.94","567.68","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","130.05","127.36","130.05","75","89.94","567.68","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.81","59.3","","1166.14","145.91","8797.03","1 through 10","89.94","567.68","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.83","78.45","","3296.61","2294.87","5653.53","11","89.94","567.68","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","AETNA [1001]","HB CH AETNA HMO / PPO","3591.28","58.3","","1530.90","1160.93","1884.08","89","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3264.80","53","","5253.92","5253.92","5253.92","1 through 10","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3572.80","58","","12181.47","12181.47","12181.47","1 through 10","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3850.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2738.12","44.45","","1910.74","891.94","1910.74","1 through 10","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","both","","","6160.00","4620.00","WELLPOINT [1015]","HB CH WELLPOINT","4799.26","77.91","","1829.79","1561.50","2617.12","88","2738.12","4799.26","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6160.00","4620.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3652.88","59.3","","1359.46","1201.30","1689.00","61","3080","4832.52","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6160.00","4620.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3652.88","59.3","","1718.92","1718.92","1718.92","1 through 10","3080","4832.52","percent of total billed charges",""
"INSERT REVISION X3 SIZE 5 19MM TRIATHLON","SUP-ITM-10322036","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6160.00","4620.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4832.52","78.45","","1910.74","1019.06","2344.84","74","3080","4832.52","percent of total billed charges",""
"Insert Tips","PX-76001127","CDM","37182","CPT","0761","RC","","","","outpatient","","","21295.00","15971.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","16705.93","78.45","","15919.53","15919.53","15919.53","1 through 10","1383.04","16705.93","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","7827.00","5870.25","AETNA [1001]","HB CH AETNA HMO / PPO","4563.14","58.3","","4315.44","4315.44","4315.44","1 through 10","2652.59","6098.02","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","7827.00","5870.25","MEDICARE [2001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","3775.96","4190.97","1 through 10","2652.59","6098.02","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","7827.00","5870.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4112.55","4107.15","4112.55","1 through 10","2652.59","6098.02","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","7827.00","5870.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4772.53","4772.53","4772.53","1 through 10","1873.9","6140.28","other","ASC "
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","7827.00","5870.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","6233.59","6233.59","6233.59","1 through 10","1873.9","6140.28","other","Multiple Surgery"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","638.00","478.50","AETNA [1001]","HB CH AETNA HMO / PPO","371.95","58.3","","351.54","351.54","351.54","1 through 10","273","497.07","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","236.00","243.00","1 through 10","273","497.07","per diem",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","262.00","270.00","1 through 10","273","497.07","per diem",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","inpatient","","","638.00","478.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","357.28","56","","363.32","363.32","363.32","1 through 10","357.28","450.43","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","451.43","451.43","451.43","1 through 10","273","567.68","other","ASC "
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","674.31","674.31","674.31","1 through 10","273","567.68","other","Multiple Surgery"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","500.51","78.45","","476.66","476.66","476.66","1 through 10","273","567.68","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","2202.00","1651.50","AETNA [1001]","HB CH AETNA HMO / PPO","1283.77","58.3","","1213.95","1213.95","1213.95","1 through 10","978.79","3663.66","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","2202.00","1651.50","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","1 through 10","978.79","3663.66","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","2202.00","1651.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1770.89","1770.89","1808.41","1 through 10","1093.63","4472.66","other","ASC "
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","AETNA [1001]","HB CH AETNA HMO / PPO","290.92","58.3","","1213.95","1213.95","1213.95","1 through 10","221.81","3663.66","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","1 through 10","221.81","3663.66","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","10122.05","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10129.66","10122.14","10129.66","1 through 10","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9670.97","9670.97","9670.97","1 through 10","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","HUMANA [1012]","HB NWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9086.93","9086.93","9086.93","1 through 10","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","MEDICARE [2001]","HB NWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9828.22","9828.22","9828.22","57","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9630.69","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9637.06","9633.66","9639.06","1 through 10","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9630.69","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9639.56","9631.66","9653.76","1 through 10","4812.67","10122.05","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","12000.00","9000.00","WELLPOINT [1015]","HB CH WELLPOINT","9349.20","77.91","","9190.50","9190.50","9190.50","1 through 10","4812.67","10122.05","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","12000.00","9000.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","12226.38","11972.37","12226.38","1 through 10","4812.67","12722.53","other","ASC "
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","12000.00","9000.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","12243.31","11989.30","12243.31","1 through 10","4812.67","12722.53","other","ASC "
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","12000.00","9000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7116.00","59.3","","6838.03","6674.67","6838.03","1 through 10","4812.67","12722.53","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","12000.00","9000.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","4812.67","","Case rate ($4,812.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","11309.77","10876.63","11309.77","1 through 10","4812.67","12722.53","other","Multiple Surgery"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","12000.00","9000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9414.00","78.45","","8971.12","8971.12","8971.12","1 through 10","4812.67","12722.53","percent of total billed charges",""
"Insrt/Place Neurostim Gen per/Gas","PX-76001565","CDM","64590","CPT","0761","RC","","","","outpatient","","","5896.00","4422.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2893.17","49.07","","30891.07","30891.07","30891.07","1 through 10","2358.4","4625.41","percent of total billed charges",""
"Insrt/Place Neurostim Gen per/Gas","PX-76001565","CDM","64590","CPT","0761","RC","","","","outpatient","","","5896.00","4422.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2953.90","50.1","","30292.08","30292.08","30933.86","1 through 10","2358.4","4625.41","percent of total billed charges",""
"Insrt/Place Neurostim Gen per/Gas","PX-76001565","CDM","64590","CPT","0761","RC","","","","outpatient","","","5896.00","4422.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4625.41","78.45","","5828.27","5828.27","5828.27","1 through 10","2358.4","4625.41","percent of total billed charges",""
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","outpatient","","","711.00","533.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","382.67","382.67","382.67","1 through 10","231.42","1176.36","other","ASC "
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","outpatient","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","2294.87","2294.87","2294.87","1 through 10","231.42","1176.36","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","103.19","103.19","1 through 10","20.98","177.65","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","187.00","140.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.89","59.3","","106.65","106.65","106.65","1 through 10","22.08","146.7","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","146.70","78.45","","139.92","139.92","139.92","1 through 10","22.08","146.7","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","54.50","26","11.2","91.2","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","96.00","72.00","TRICARE [160005]","HB NWH TRICARE","91.20","95","","13.77","13.77","13.77","1 through 10","11.2","91.2","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","29","11.79","75.31","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","28","11.79","75.31","percent of total billed charges",""
"Intentional Self-Harm And Attempted Suicide,EXTREME","817","DRG","","","","","","","","inpatient","","","88782.31","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","15870.60","","Fee schedule rate ($15,870.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15870.48","15870.48","15870.48","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","30313.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20256.11","","Standard inlier is a Case rate ($20,256.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,993, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,875.27) for the length of stay and the standard reimbursement.","20256.11","20256.11","20256.11","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","30313.30","","MASSHEALTH [3001]","HB NWH MEDICAID","12371.82","","Case rate ($13,328.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,758.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13362.97","13362.97","13362.97","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","30313.30","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","12371.82","","Case rate ($13,328.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,758.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","30313.30","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","12371.82","","Case rate ($13,328.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,758.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8312.89","8312.89","13362.96","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MINOR","817","DRG","","","","","","","","inpatient","","","9949.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9888.42","","Standard inlier is a Case rate ($9,888.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,092, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,403.62) for the length of stay and the standard reimbursement.","9438.94","9438.94","9888.41","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","12888.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12466.52","","Standard inlier is a Case rate ($12,466.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,553, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,769.57) for the length of stay and the standard reimbursement.","12466.51","12466.51","12466.51","1 through 10","4963.81","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","12888.64","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8949.30","","Case rate ($9,641.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,071.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,499.45 and the sum of the standard inlier and any outlier amount.","3006.61","3006.61","3006.61","1 through 10","4963.81","39796.65","case rate",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","583.00","437.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","425.59","other","OPPS APC"
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","583.00","437.25","MEDICARE [2001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","51","27.63","425.59","other","OPPS APC"
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","583.00","437.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.90","28.70","28.90","1 through 10","27.63","425.59","other","OPPS APC"
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","583.00","437.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","29.00","28.50","32.50","1 through 10","27.63","425.59","other","OPPS APC"
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","outpatient","","","583.00","437.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","345.72","59.3","","332.26","324.32","332.26","1 through 10","28.35","457.36","percent of total billed charges",""
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1330.00","997.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","970.9","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1330.00","997.50","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","36","42.07","970.9","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1330.00","997.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.39","130.17","1 through 10","42.07","970.9","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","44.28","43.90","44.28","1 through 10","42.07","970.9","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","outpatient","","","1330.00","997.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","788.69","59.3","","757.70","757.70","757.70","1 through 10","61.36","1043.39","percent of total billed charges",""
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","outpatient","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1043.39","78.45","","589.09","589.09","589.09","1 through 10","61.36","1043.39","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","633.00","474.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","462.09","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","633.00","474.75","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","267","42.07","462.09","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","633.00","474.75","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","87.85","1 through 10","42.07","462.09","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","633.00","474.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","43.39","130.17","39","42.07","462.09","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","633.00","474.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.80","43.39","44.28","28","42.07","462.09","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","outpatient","","","633.00","474.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","375.37","59.3","","360.98","360.98","360.98","1 through 10","61.36","496.59","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","outpatient","","","633.00","474.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","496.59","78.45","","473.58","467.11","473.58","1 through 10","61.36","496.59","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB CH AETNA HMO / PPO","469.90","58.3","","444.53","444.53","444.53","1 through 10","42.07","588.38","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.46","45.56","46.46","12","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","32","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","CIGNA [1006]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.34","40.34","40.34","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","ELDER SERVICES [1037]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","850","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","88.56","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","40.74","43.79","128","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","41.16","44.28","74","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","477.96","59.3","","459.42","459.42","459.42","1 through 10","61.36","632.31","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","632.31","78.45","","602.74","357.19","602.74","1 through 10","61.36","632.31","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB CH AETNA HMO / PPO","469.90","58.3","","444.53","444.53","444.53","1 through 10","42.07","588.38","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.46","45.56","46.46","12","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","32","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","CIGNA [1006]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.34","40.34","40.34","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","ELDER SERVICES [1037]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","850","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","88.56","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","40.74","43.79","128","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","41.16","44.28","74","42.07","588.38","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","477.96","59.3","","459.42","459.42","459.42","1 through 10","61.36","632.31","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","632.31","78.45","","602.74","357.19","602.74","1 through 10","61.36","632.31","percent of total billed charges",""
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","423.00","317.25","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","329.56","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","outpatient","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","240.85","240.85","240.85","1 through 10","61.36","331.84","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB CH AETNA HMO / PPO","469.90","58.3","","444.53","444.53","444.53","1 through 10","42.07","588.38","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.46","45.56","46.46","12","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","32","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","CIGNA [1006]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.34","40.34","40.34","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","ELDER SERVICES [1037]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","850","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","88.56","1 through 10","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","40.74","43.79","128","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","41.16","44.28","74","42.07","588.38","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","477.96","59.3","","459.42","459.42","459.42","1 through 10","61.36","632.31","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","806.00","604.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","632.31","78.45","","602.74","357.19","602.74","1 through 10","61.36","632.31","percent of total billed charges",""
"Interspinous Process Distration Device T3","PX-27000143","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","5530.54","5530.54","5530.54","1 through 10","3000","4707","percent of total billed charges",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","16988.62","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","10678.84","","Case rate ($11,504.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,934.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11534.35","11534.35","11534.35","1 through 10","2189","46231.45","case rate",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","13848.50","10386.37","MEDICARE [2001]","HB NWH MEDICARE","9041.33","","Case rate ($9,041.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,447.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,589.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,570.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,412.93. The transfer operating threshold is the transfer adjustment factor * $8,447.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.39. The transfer capital threshold is the transfer adjustment factor * $628.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","728.09","728.09","1343.25","1 through 10","8058.48","9742.51","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","34599.12","25949.34","MEDICARE [2001]","HB NWH MEDICARE","16350.56","","Case rate ($16,350.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,796.47, add-ons for qualifying new technology services are included. If operating cost exceeds $61,938.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,191.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,101.07. The transfer operating threshold is the transfer adjustment factor * $16,796.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.49. The transfer capital threshold is the transfer adjustment factor * $1,249.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17982.17","17981.94","18014.50","12","16023.55","18631.8649","other","Inpatient Replacement Plans DRG"
"Interstitial Lung Disease Without Cc/McC","198","MS-DRG","","","","","","","","inpatient","","","18680.52","14010.39","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6080.99","","Case rate ($6,205.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,374.32, add-ons for qualifying new technology services are included. If operating cost exceeds $51,516.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,416.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,730.92. The transfer operating threshold is the transfer adjustment factor * $6,374.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.19. The transfer capital threshold is the transfer adjustment factor * $474.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5982.26","5982.26","5982.26","1 through 10","6080.99","6926.2556","other","Inpatient DRG"
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11352.90","","Standard inlier is a Case rate ($11,352.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,611.59) for the length of stay and the standard reimbursement.","10837.00","10837.00","10837.00","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12195.28","","Standard inlier is a Case rate ($12,195.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,731.07) for the length of stay and the standard reimbursement.","12195.27","11640.94","12195.28","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9827.6718","","Fee schedule rate ($9,827.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9827.6718","9827.68","9827.68","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10319.0051","","Fee schedule rate ($10,319.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10319.0051","9921.22","9921.22","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","MASSHEALTH [3001]","HB NWH MEDICAID","4082.82","","Case rate ($4,398.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,828.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4409.90","4409.90","4409.90","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","16611.90","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4082.82","","Case rate ($4,398.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,828.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4409.90","4409.90","4409.90","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14709.00","","Standard inlier is a Case rate ($14,709). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,088) for the length of stay and the standard reimbursement.","14709.00","14709.00","14709.00","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15800.40","","Standard inlier is a Case rate ($15,800.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,242.80) for the length of stay and the standard reimbursement.","15082.20","15082.20","15800.40","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9827.6718","","Fee schedule rate ($13,345.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9827.6718","13345.24","13345.24","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10319.0051","","Fee schedule rate ($14,012.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10319.0051","14012.44","14012.44","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","14679.62","","Fee schedule rate ($14,679.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14679.62","14679.62","14679.62","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","MASSHEALTH [3001]","HB NWH MEDICAID","5542.76","","Case rate ($5,971.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,401.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5986.81","5986.81","5986.81","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10471.04","","Fee schedule rate ($10,471.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7085.84","7085.84","7085.84","1 through 10","4082.82","97325.29","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","16575.40","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22318.51","","Fee schedule rate ($22,318.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15103.13","15103.13","15103.13","1 through 10","4082.82","97325.29","case rate",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9015.77","","Case rate ($8,753.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,084.26. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9119.94","9119.94","9119.94","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9624.33","","Case rate ($9,624.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,955.41. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9567.34","9567.34","9567.34","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","9624.33","","Case rate ($9,624.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,955.41. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8684.61","8684.61","8684.61","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","HUMANA [1012]","HB NWH MEDICARE","9624.33","","Case rate ($9,624.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,955.41. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2980.60","2980.60","2980.60","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","MEDICARE [2001]","HB NWH MEDICARE","9624.33","","Case rate ($9,624.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,955.41. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9705.46","6945.07","9722.91","42","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8578.11","","Case rate ($8,753.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,084.26. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8673.97","8671.36","8701.49","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","8578.11","","Case rate ($8,753.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,084.26. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9924.79","9924.79","9924.79","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","32384.03","24288.02","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8578.11","","Case rate ($8,753.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,991.88, add-ons for qualifying new technology services are included. If operating cost exceeds $54,134.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,084.26. The transfer operating threshold is the transfer adjustment factor * $8,991.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.91. The transfer capital threshold is the transfer adjustment factor * $668.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8710.11","8710.11","8710.11","1 through 10","8578.11","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","41668.28","31251.21","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","19157.20","","Case rate ($19,157.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,898.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,040.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,825.73. The transfer operating threshold is the transfer adjustment factor * $17,898.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.46. The transfer capital threshold is the transfer adjustment factor * $1,331.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15248.00","15248.00","15248.00","1 through 10","17074.7","20642.92","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","41668.28","31251.21","MEDICARE [2001]","HB NWH MEDICARE","19157.20","","Case rate ($19,157.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,898.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,040.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,825.73. The transfer operating threshold is the transfer adjustment factor * $17,898.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.46. The transfer capital threshold is the transfer adjustment factor * $1,331.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18985.26","8437.05","19019.40","38","17074.7","20642.92","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","41668.28","31251.21","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","17074.70","","Case rate ($17,423.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,898.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,040.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,091.70. The transfer operating threshold is the transfer adjustment factor * $17,898.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.46. The transfer capital threshold is the transfer adjustment factor * $1,331.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15088.58","15084.00","16986.91","1 through 10","17074.7","20642.92","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","41668.28","31251.21","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","17074.70","","Case rate ($17,423.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,898.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,040.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,091.70. The transfer operating threshold is the transfer adjustment factor * $17,898.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.46. The transfer capital threshold is the transfer adjustment factor * $1,331.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19204.59","19204.59","19204.59","1 through 10","17074.7","20642.92","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","41668.28","31251.21","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17074.70","","Case rate ($17,423.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,898.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,040.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,273.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,091.70. The transfer operating threshold is the transfer adjustment factor * $17,898.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.46. The transfer capital threshold is the transfer adjustment factor * $1,331.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16990.80","16990.80","24965.35","1 through 10","17074.7","20642.92","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","32292.25","24219.19","MEDICARE [2001]","HB NWH MEDICARE","6519.74","","Case rate ($6,519.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,091.30, add-ons for qualifying new technology services are included. If operating cost exceeds $51,233.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,395.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,066.60. The transfer operating threshold is the transfer adjustment factor * $6,091.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.13. The transfer capital threshold is the transfer adjustment factor * $453.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6581.06","6569.26","6581.06","1 through 10","5811.01","6806.5987","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","32292.25","24219.19","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","5811.01","","Case rate ($5,929.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,091.30, add-ons for qualifying new technology services are included. If operating cost exceeds $51,233.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,395.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,476.46. The transfer operating threshold is the transfer adjustment factor * $6,091.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.13. The transfer capital threshold is the transfer adjustment factor * $453.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5902.02","5902.02","5902.02","1 through 10","5811.01","6806.5987","other","Inpatient DRG"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1301.00","975.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","651.80","50.1","","248.00","248.00","248.00","1 through 10","558.13","1873.9","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","4168.58","2865.62","4168.58","1 through 10","328.19","596.01","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","2552.27","2552.27","2552.27","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","4822.09","4822.09","4822.09","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","5565.65","465.60","5565.65","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","3178.22","1589.11","4680.84","1 through 10","306","600.14","percent of total billed charges",""
"Intravascular US Noncoronary Rs&I Intial Vessel","PX-40000142","CDM","37252","CPT","0402","RC","","","","both","","","2068.00","1551.00","AETNA [1001]","HB CH AETNA HMO / PPO","1205.64","58.3","","1100.93","1100.93","1100.93","1 through 10","919.23","1611.18","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","68.61","1 through 10","14.78","117.8","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","93.02","93.02","93.02","1 through 10","15.54","97.28","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","AETNA [1001]","HB CH AETNA HMO / PPO","1925.65","58.3","","48.90","46.54","48.90","1 through 10","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1750.59","53","","91.65","91.65","91.65","1 through 10","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1915.74","58","","51.23","51.23","51.23","1 through 10","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2064.38","62.5","","65.12","36.89","65.12","1 through 10","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2411.19","73","","46.29","46.29","46.29","1 through 10","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3303.00","2477.25","WELLPOINT [1015]","HB CH WELLPOINT","2573.37","77.91","","64.65","45.40","120.92","18","1468.18","2573.37","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3303.00","2477.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2591.20","78.45","","276.77","63.10","312.43","11","1651.5","2591.2","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","48.90","46.54","48.90","1 through 10","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","91.65","91.65","91.65","1 through 10","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","34.80","58","","51.23","51.23","51.23","1 through 10","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37.50","62.5","","65.12","36.89","65.12","1 through 10","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","46.29","46.29","46.29","1 through 10","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","64.65","45.40","120.92","18","26.67","46.75","percent of total billed charges",""
"INTRODUCER CLOSUREFAST 7FR 11CM VASCULAR ADULT MICRO VENEFIT SHEATH DILATOR UNDER WIRE GUIDEWIRE NEEDLE","SUP-ITM-10022896","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","276.77","63.10","312.43","11","30","47.07","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","AETNA [1001]","HB CH AETNA HMO / PPO","1061.64","58.3","","48.90","46.54","48.90","1 through 10","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","965.13","53","","91.65","91.65","91.65","1 through 10","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1056.18","58","","51.23","51.23","51.23","1 through 10","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1138.13","62.5","","65.12","36.89","65.12","1 through 10","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1329.33","73","","46.29","46.29","46.29","1 through 10","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","1821.00","1365.75","WELLPOINT [1015]","HB CH WELLPOINT","1418.74","77.91","","64.65","45.40","120.92","18","809.43","1418.74","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1821.00","1365.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1428.57","78.45","","276.77","63.10","312.43","11","910.5","1428.57","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","48.90","46.54","48.90","1 through 10","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","91.65","91.65","91.65","1 through 10","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.90","58","","51.23","51.23","51.23","1 through 10","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","534.38","62.5","","65.12","36.89","65.12","1 through 10","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","46.29","46.29","46.29","1 through 10","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","64.65","45.40","120.92","18","380.05","666.13","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","276.77","63.10","312.43","11","427.5","670.75","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","AETNA [1001]","HB CH AETNA HMO / PPO","268.18","58.3","","0.44","0.31","0.46","18007","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","243.80","53","","16.38","16.38","16.38","1 through 10","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","335.80","73","","23.10","23.10","23.10","1 through 10","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","460.00","345.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.76","70.6","","0.30","0.30","0.30","76","204.47","324.76","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","460.00","345.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.12","52.2","","0.40","0.04","0.55","458","230","240.12","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","AETNA [1001]","HB CH AETNA HMO / PPO","97.36","58.3","","0.44","0.31","0.46","18007","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.51","53","","16.38","16.38","16.38","1 through 10","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","121.91","73","","23.10","23.10","23.10","1 through 10","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","167.00","125.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.90","70.6","","0.30","0.30","0.30","76","74.23","117.9","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","167.00","125.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.17","52.2","","0.40","0.04","0.55","458","83.5","87.17","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","0.44","0.31","0.46","18007","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.09","53","","16.38","16.38","16.38","1 through 10","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","38.69","73","","23.10","23.10","23.10","1 through 10","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","53.00","39.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.42","70.6","","0.30","0.30","0.30","76","23.56","37.42","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","53.00","39.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.67","52.2","","0.40","0.04","0.55","458","26.5","27.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","AETNA [1001]","HB CH AETNA HMO / PPO","50.72","58.3","","0.44","0.31","0.46","18007","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.11","53","","16.38","16.38","16.38","1 through 10","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","63.51","73","","23.10","23.10","23.10","1 through 10","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.42","70.6","","0.30","0.30","0.30","76","38.67","61.42","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","87.00","65.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.41","52.2","","0.40","0.04","0.55","458","43.5","45.41","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","0.44","0.31","0.46","18007","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","22.79","53","","16.38","16.38","16.38","1 through 10","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","31.39","73","","23.10","23.10","23.10","1 through 10","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","30.36","70.6","","0.30","0.30","0.30","76","19.11","30.36","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","22.45","52.2","","0.40","0.04","0.55","458","21.5","22.45","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.06","58.3","","0.44","0.31","0.46","18007","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.87","53","","16.38","16.38","16.38","1 through 10","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","57.67","73","","23.10","23.10","23.10","1 through 10","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.77","70.6","","0.30","0.30","0.30","76","35.12","55.77","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","79.00","59.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","41.24","52.2","","0.40","0.04","0.55","458","39.5","41.24","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","AETNA [1001]","HB CH AETNA HMO / PPO","23.32","58.3","","0.44","0.31","0.46","18007","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","21.20","53","","16.38","16.38","16.38","1 through 10","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","29.20","73","","23.10","23.10","23.10","1 through 10","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","inpatient","","","40.00","30.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.24","70.6","","0.30","0.30","0.30","76","17.78","28.24","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","40.00","30.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.88","52.2","","0.40","0.04","0.55","458","20","20.88","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","510","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","43.07","73","","41.61","41.61","41.61","1 through 10","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.27","53","","30.21","30.21","30.21","1 through 10","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.07","73","","32.32","5.82","40.15","1 through 10","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","TRICARE [160005]","HB NWH TRICARE","56.05","95","","7.80","7.41","7.80","1 through 10","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.23","44.45","","43.82","25.97","43.82","22","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.23","44.45","","43.82","43.82","43.82","1 through 10","6.34","56.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.99","59.3","","33.40","33.40","33.40","544","6.67","46.29","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","43.82","43.82","43.82","1 through 10","6.67","46.29","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","43.82","25.97","43.82","452","6.67","46.29","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","AETNA [1001]","HB CH AETNA HMO / PPO","41.39","58.3","","39.12","39.12","39.12","501","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","51.83","73","","50.37","50.37","50.37","1 through 10","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","37.63","53","","36.57","36.57","36.57","1 through 10","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","51.83","73","","39.12","7.86","48.91","1 through 10","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","TRICARE [160005]","HB NWH TRICARE","67.45","95","","10.53","10.00","10.53","1 through 10","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.56","44.45","","53.05","31.44","53.05","21","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.56","44.45","","53.05","53.05","53.05","1 through 10","8.57","67.45","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","40.43","534","9.02","55.7","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","53.05","53.05","1 through 10","9.02","55.7","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","31.44","53.05","439","9.02","55.7","percent of total billed charges",""
"Irreversible Electroporation Ablation of Lymph Node","PX-76002337","CDM","38999","CPT","0761","RC","","","","outpatient","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3223.51","78.45","","389.01","389.01","389.01","1 through 10","970.06","3223.51","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","711.00","533.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.21","284.21","284.21","1 through 10","231.42","553.94","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","711.00","533.25","MEDICARE [2001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","231.42","553.94","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.05","283.05","283.05","1 through 10","231.42","553.94","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","711.00","533.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","382.14","382.14","382.14","1 through 10","231.42","774.58","other","ASC "
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","711.00","533.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","382.67","374.73","382.67","1 through 10","231.42","774.58","other","ASC "
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","255.00","191.25","MEDICARE [2001]","HB NWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","11","67.01","217.45","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","65.43","69.13","35","67.01","217.45","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","145.33","145.33","145.33","1 through 10","92.3","266.3","percent of total billed charges",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","89107.53","66830.65","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15224.25","","Case rate ($15,224.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $60,781.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,105.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,060.83. The transfer operating threshold is the transfer adjustment factor * $15,639.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.42. The transfer capital threshold is the transfer adjustment factor * $1,163.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16755.33","16755.33","16755.33","1 through 10","14919.77","17611.3201","other","Inpatient Replacement Plans DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","89107.53","66830.65","MEDICARE [2001]","HB NWH MEDICARE","15224.25","","Case rate ($15,224.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $60,781.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,105.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,060.83. The transfer operating threshold is the transfer adjustment factor * $15,639.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.42. The transfer capital threshold is the transfer adjustment factor * $1,163.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16997.21","16997.21","16997.21","1 through 10","14919.77","17611.3201","other","Inpatient Replacement Plans DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","89107.53","66830.65","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14919.77","","Case rate ($15,224.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $60,781.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,105.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,060.83. The transfer operating threshold is the transfer adjustment factor * $15,639.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.42. The transfer capital threshold is the transfer adjustment factor * $1,163.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","72.56","72.56","72.56","1 through 10","14919.77","17611.3201","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","96325.35","72244.01","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","23887.32","","Case rate ($23,887.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,538.75, add-ons for qualifying new technology services are included. If operating cost exceeds $69,681.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,767.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $22,061.87. The transfer operating threshold is the transfer adjustment factor * $24,538.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,825.44. The transfer capital threshold is the transfer adjustment factor * $1,825.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23312.66","23312.66","23312.66","1 through 10","23409.57","26733.9226","other","Inpatient Replacement Plans DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","96325.35","72244.01","MEDICARE [2001]","HB NWH MEDICARE","23887.32","","Case rate ($23,887.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,538.75, add-ons for qualifying new technology services are included. If operating cost exceeds $69,681.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,767.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $22,061.87. The transfer operating threshold is the transfer adjustment factor * $24,538.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,825.44. The transfer capital threshold is the transfer adjustment factor * $1,825.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25848.10","25848.10","25848.10","1 through 10","23409.57","26733.9226","other","Inpatient Replacement Plans DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC","063","MS-DRG","","","","","","","","inpatient","","","67875.17","50906.38","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12162.42","","Case rate ($12,162.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,494.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,636.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,871.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,232.98. The transfer operating threshold is the transfer adjustment factor * $12,494.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.44. The transfer capital threshold is the transfer adjustment factor * $929.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12117.88","12117.88","12117.88","1 through 10","11919.17","13892.0672","other","Inpatient Replacement Plans DRG"
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","137.21","1 through 10","23.1","125.16","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","1 through 10","20.4","124.73","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","93.03","93.03","279.07","1 through 10","20.4","124.73","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB CH AETNA HMO / PPO","124.18","58.3","","117.37","117.37","234.74","138","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","207.00","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.80","65","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","155.49","73","","113.36","113.36","113.36","1 through 10","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.81","53.70","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","54.79","54.79","15","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.68","44.45","","94.31","94.31","152.42","1 through 10","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.70","53.70","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.68","44.45","","94.31","94.31","94.31","1 through 10","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","WELLPOINT [1015]","HB CH WELLPOINT","165.95","77.91","","163.03","163.03","163.04","23","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","inpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.38","70.6","","1791.55","94.31","1791.55","1 through 10","119.28","150.38","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","213.00","159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.31","59.3","","201.50","121.30","621.00","145","62.55","167.1","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","207.00","207.00","207.00","1 through 10","62.55","167.1","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","621.00","94.31","6270.78","75","62.55","167.1","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","AETNA [1001]","HB CH AETNA HMO / PPO","338.72","58.3","","320.36","320.36","640.72","1 through 10","223.15","728.13","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","240.72","240.72","240.72","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","565.00","565.00","565.00","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","MEDICARE [2001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","750.63","27","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","132.98","132.98","132.98","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","250.21","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","581.00","435.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","344.53","59.3","","331.09","331.09","554.66","28","290.5","462.33","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","455.79","78.45","","434.37","257.41","1695.00","17","290.5","462.33","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB CH AETNA HMO / PPO","214.54","58.3","","202.99","202.99","202.99","1 through 10","80.29","286.71","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","84.52","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","268.64","73","","196.27","196.27","196.27","1 through 10","80.29","286.71","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","84.52","84.52","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB CH WELLPOINT","286.71","77.91","","281.96","281.96","281.96","1 through 10","80.29","286.71","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","368.00","276.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","218.22","59.3","","767.79","209.79","1074.00","1 through 10","98.67","288.7","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","AETNA [1001]","HB CH AETNA HMO / PPO","420.34","58.3","","397.47","397.47","397.47","61","237.7","728.13","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","258.17","257.47","258.37","24","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","52","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","HUMANA [1012]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","245.21","245.21","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MEDICARE [2001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","963","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MOLINA [1014]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","496.42","496.42","496.42","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","245.21","132","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.48","44.45","","538.93","538.93","538.93","1 through 10","237.7","728.13","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.21","230.19","250.21","57","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","721.00","540.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","427.55","59.3","","410.79","410.79","1460.24","55","309.09","764.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","721.00","540.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","565.62","78.45","","701.00","701.00","701.00","1 through 10","309.09","764.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","721.00","540.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","565.62","78.45","","538.93","319.38","620.55","64","309.09","764.73","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB CH AETNA HMO / PPO","163.82","58.3","","154.79","154.79","154.79","45","52.05","218.93","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","12","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.80","289","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","MOLINA [1014]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.70","108.70","108.70","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","53.70","32","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","54.79","54.79","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","50.82","54.79","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","WELLPOINT [1015]","HB CH WELLPOINT","218.93","77.91","","215.01","215.01","215.01","17","52.05","218.93","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","inpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.39","70.6","","124.38","124.38","124.38","1 through 10","157.36","198.39","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","281.00","210.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.63","59.3","","159.98","159.98","273.00","11","62.55","220.44","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.44","78.45","","209.88","124.38","209.88","23","62.55","220.44","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB CH AETNA HMO / PPO","125.35","58.3","","118.50","118.50","118.50","1 through 10","113.95","167.51","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","134.38","62.5","","75.48","75.48","75.48","1 through 10","113.95","167.51","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","AETNA [1001]","HB CH AETNA HMO / PPO","453.57","58.3","","429.22","429.22","429.22","77","110.41","728.13","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","242.22","262.72","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","14","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","MEDICARE [2001]","HB NWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","200","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","229.25","245.21","29","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.21","250.21","250.21","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.82","44.45","","581.98","558.87","581.98","1 through 10","110.41","728.13","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.71","229.26","250.21","15","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","inpatient","","","778.00","583.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.68","56","","443.60","310.12","443.60","1 through 10","435.68","549.27","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","inpatient","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","549.27","70.6","","3276.00","581.98","3276.00","1 through 10","435.68","549.27","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","778.00","583.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","461.35","59.3","","443.60","443.60","769.74","43","204.65","610.34","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","610.34","78.45","","581.98","344.89","757.00","51","204.65","610.34","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","AETNA [1001]","HB CH AETNA HMO / PPO","144.00","58.3","","272.16","136.08","272.16","38","109.79","192.44","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","143.26","58","","121.20","121.20","121.20","1 through 10","109.79","192.44","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","143.26","58","","139.12","138.48","142.56","1 through 10","109.79","192.44","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","150.42","60.9","","149.76","145.94","149.76","1 through 10","109.79","192.44","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","154.38","62.5","","153.60","153.60","153.60","1 through 10","109.79","192.44","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","247.00","185.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.47","59.3","","150.21","140.64","310.36","16","123.5","193.77","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","247.00","185.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","193.77","78.45","","240.00","240.00","240.00","1 through 10","123.5","193.77","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","247.00","185.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","193.77","78.45","","109.34","109.34","369.02","1 through 10","123.5","193.77","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","175.20","175.20","175.21","102","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.92","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","HUMANA [1012]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.80","51.85","54.80","292","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","MOLINA [1014]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.70","108.70","108.70","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","339.52","339.52","339.53","12","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","53.70","35","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","54.79","103.70","14","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","140.78","140.78","228.25","1 through 10","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.70","54.79","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","243.37","243.37","301.00","18","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","inpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","224.51","70.6","","475.12","140.78","475.12","1 through 10","178.08","224.51","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","181.08","181.07","543.23","126","62.55","249.47","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","927.00","927.00","927.00","1 through 10","62.55","249.47","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","237.56","140.78","475.12","30","62.55","249.47","percent of total billed charges",""
"Jak2 Exons 12 - 15 Sequencing","PX-31000942","CDM","0027U","CPT","0310","RC","","","","both","","","1211.00","908.25","AETNA [1001]","HB CH AETNA HMO / PPO","706.01","58.3","","667.93","667.93","667.93","1 through 10","119.47","1150.45","percent of total billed charges",""
"Jak2 Exons 12 - 15 Sequencing","PX-31000942","CDM","0027U","CPT","0310","RC","","","","outpatient","","","1211.00","908.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","606.71","50.1","","746.85","746.85","746.85","1 through 10","353.72","950.03","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","AETNA [1001]","HB CH AETNA HMO / PPO","89.55","58.3","","464.71","67.87","1012.10","221","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","89.55","58.3","","293.04","293.04","293.04","11","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.41","53","","983.89","983.89","983.89","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","89.09","58","","677.18","677.18","677.18","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","96.00","62.5","","46.58","46.58","46.58","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","112.13","73","","747.15","747.15","747.15","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.28","44.45","","1141.67","481.21","1141.67","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.28","44.45","","76.54","76.54","76.54","1 through 10","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.60","115.20","WELLPOINT [1015]","HB CH WELLPOINT","119.67","77.91","","273.64","94.28","1367.51","138","68.28","119.67","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.60","115.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.08","59.3","","720.78","230.14","2010.94","427","76.8","120.5","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.60","115.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","91.08","59.3","","344.45","344.45","344.45","1 through 10","76.8","120.5","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.60","115.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","120.50","78.45","","1120.13","1120.13","1120.13","1 through 10","76.8","120.5","percent of total billed charges",""
"K-WIRE 3.2MM ERGONOMIC THREADED TROCAR TIP","SUP-ITM-10287922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.60","115.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.50","78.45","","456.17","105.33","1284.66","242","76.8","120.5","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","AETNA [1001]","HB CH AETNA HMO / PPO","13.15","58.3","","464.71","67.87","1012.10","221","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","13.15","58.3","","293.04","293.04","293.04","11","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","11.96","53","","983.89","983.89","983.89","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13.08","58","","677.18","677.18","677.18","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14.10","62.5","","46.58","46.58","46.58","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.47","73","","747.15","747.15","747.15","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.03","44.45","","1141.67","481.21","1141.67","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.03","44.45","","76.54","76.54","76.54","1 through 10","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.56","16.92","WELLPOINT [1015]","HB CH WELLPOINT","17.58","77.91","","273.64","94.28","1367.51","138","10.03","17.58","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.56","16.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.38","59.3","","720.78","230.14","2010.94","427","11.28","17.7","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.56","16.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","13.38","59.3","","344.45","344.45","344.45","1 through 10","11.28","17.7","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.56","16.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","17.70","78.45","","1120.13","1120.13","1120.13","1 through 10","11.28","17.7","percent of total billed charges",""
"K-WIRE 9INX.062IN DIAMOND STAINLESS BX/5EA","SUP-ITM-10028357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.56","16.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.70","78.45","","456.17","105.33","1284.66","242","11.28","17.7","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","464.71","67.87","1012.10","221","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","38.48","58.3","","293.04","293.04","293.04","11","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.98","53","","983.89","983.89","983.89","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","38.28","58","","677.18","677.18","677.18","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","41.25","62.5","","46.58","46.58","46.58","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","48.18","73","","747.15","747.15","747.15","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.34","44.45","","1141.67","481.21","1141.67","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.34","44.45","","76.54","76.54","76.54","1 through 10","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB CH WELLPOINT","51.42","77.91","","273.64","94.28","1367.51","138","29.34","51.42","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","720.78","230.14","2010.94","427","33","51.78","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","39.14","59.3","","344.45","344.45","344.45","1 through 10","33","51.78","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","1120.13","1120.13","1120.13","1 through 10","33","51.78","percent of total billed charges",""
"K-WIRE BONE .034IN TROCAR TIP LASER MARKED BX/6EA","SUP-ITM-10318199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","456.17","105.33","1284.66","242","33","51.78","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","464.71","67.87","1012.10","221","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","293.04","293.04","293.04","11","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","983.89","983.89","983.89","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","677.18","677.18","677.18","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","46.58","46.58","46.58","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","747.15","747.15","747.15","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","1141.67","481.21","1141.67","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","76.54","76.54","76.54","1 through 10","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","273.64","94.28","1367.51","138","60.01","105.18","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","720.78","230.14","2010.94","427","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","344.45","344.45","344.45","1 through 10","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1120.13","1120.13","1120.13","1 through 10","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS BLUNT END","SUP-ITM-10104602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","456.17","105.33","1284.66","242","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","AETNA [1001]","HB CH AETNA HMO / PPO","99.66","58.3","","464.71","67.87","1012.10","221","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.66","58.3","","293.04","293.04","293.04","11","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.60","53","","983.89","983.89","983.89","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","99.15","58","","677.18","677.18","677.18","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","106.84","62.5","","46.58","46.58","46.58","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.79","73","","747.15","747.15","747.15","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.98","44.45","","1141.67","481.21","1141.67","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.98","44.45","","76.54","76.54","76.54","1 through 10","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","WELLPOINT [1015]","HB CH WELLPOINT","133.18","77.91","","273.64","94.28","1367.51","138","75.98","133.18","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.37","59.3","","720.78","230.14","2010.94","427","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","101.37","59.3","","344.45","344.45","344.45","1 through 10","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","134.10","78.45","","1120.13","1120.13","1120.13","1 through 10","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.10","78.45","","456.17","105.33","1284.66","242","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","464.71","67.87","1012.10","221","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","36.73","58.3","","293.04","293.04","293.04","11","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","33.39","53","","983.89","983.89","983.89","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","36.54","58","","677.18","677.18","677.18","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","39.38","62.5","","46.58","46.58","46.58","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","45.99","73","","747.15","747.15","747.15","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","1141.67","481.21","1141.67","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","76.54","76.54","76.54","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB CH WELLPOINT","49.08","77.91","","273.64","94.28","1367.51","138","28","49.08","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","720.78","230.14","2010.94","427","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","37.36","59.3","","344.45","344.45","344.45","1 through 10","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","1120.13","1120.13","1120.13","1 through 10","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","456.17","105.33","1284.66","242","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","464.71","67.87","1012.10","221","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","34.98","58.3","","293.04","293.04","293.04","11","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","983.89","983.89","983.89","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","34.80","58","","677.18","677.18","677.18","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37.50","62.5","","46.58","46.58","46.58","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","747.15","747.15","747.15","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","1141.67","481.21","1141.67","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","76.54","76.54","76.54","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","273.64","94.28","1367.51","138","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","720.78","230.14","2010.94","427","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","35.58","59.3","","344.45","344.45","344.45","1 through 10","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","1120.13","1120.13","1120.13","1 through 10","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","456.17","105.33","1284.66","242","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","AETNA [1001]","HB CH AETNA HMO / PPO","31.34","58.3","","464.71","67.87","1012.10","221","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.34","58.3","","293.04","293.04","293.04","11","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.49","53","","983.89","983.89","983.89","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","31.18","58","","677.18","677.18","677.18","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33.60","62.5","","46.58","46.58","46.58","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.24","73","","747.15","747.15","747.15","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.90","44.45","","1141.67","481.21","1141.67","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.90","44.45","","76.54","76.54","76.54","1 through 10","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","WELLPOINT [1015]","HB CH WELLPOINT","41.88","77.91","","273.64","94.28","1367.51","138","23.9","41.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.88","59.3","","720.78","230.14","2010.94","427","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","31.88","59.3","","344.45","344.45","344.45","1 through 10","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","1120.13","1120.13","1120.13","1 through 10","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","456.17","105.33","1284.66","242","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","AETNA [1001]","HB CH AETNA HMO / PPO","33.58","58.3","","464.71","67.87","1012.10","221","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","33.58","58.3","","293.04","293.04","293.04","11","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.53","53","","983.89","983.89","983.89","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","33.41","58","","677.18","677.18","677.18","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","36.00","62.5","","46.58","46.58","46.58","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","42.05","73","","747.15","747.15","747.15","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.60","44.45","","1141.67","481.21","1141.67","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.60","44.45","","76.54","76.54","76.54","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","WELLPOINT [1015]","HB CH WELLPOINT","44.88","77.91","","273.64","94.28","1367.51","138","25.6","44.88","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.16","59.3","","720.78","230.14","2010.94","427","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","34.16","59.3","","344.45","344.45","344.45","1 through 10","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","1120.13","1120.13","1120.13","1 through 10","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","456.17","105.33","1284.66","242","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","AETNA [1001]","HB CH AETNA HMO / PPO","590.83","58.3","","464.71","67.87","1012.10","221","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","590.83","58.3","","293.04","293.04","293.04","11","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.12","53","","983.89","983.89","983.89","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","587.79","58","","677.18","677.18","677.18","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","633.39","62.5","","46.58","46.58","46.58","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","747.15","747.15","747.15","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","1141.67","481.21","1141.67","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","76.54","76.54","76.54","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","WELLPOINT [1015]","HB CH WELLPOINT","789.56","77.91","","273.64","94.28","1367.51","138","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","600.96","59.3","","720.78","230.14","2010.94","427","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","600.96","59.3","","344.45","344.45","344.45","1 through 10","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","1120.13","1120.13","1120.13","1 through 10","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","456.17","105.33","1284.66","242","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","AETNA [1001]","HB CH AETNA HMO / PPO","97.37","58.3","","464.71","67.87","1012.10","221","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.37","58.3","","293.04","293.04","293.04","11","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.52","53","","983.89","983.89","983.89","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","96.87","58","","677.18","677.18","677.18","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","104.38","62.5","","46.58","46.58","46.58","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","121.92","73","","747.15","747.15","747.15","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.24","44.45","","1141.67","481.21","1141.67","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.24","44.45","","76.54","76.54","76.54","1 through 10","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","WELLPOINT [1015]","HB CH WELLPOINT","130.12","77.91","","273.64","94.28","1367.51","138","74.24","130.12","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.04","59.3","","720.78","230.14","2010.94","427","83.51","131.02","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","99.04","59.3","","344.45","344.45","344.45","1 through 10","83.51","131.02","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","131.02","78.45","","1120.13","1120.13","1120.13","1 through 10","83.51","131.02","percent of total billed charges",""
"K-WIRE BONE 1.2MMX100 ASNIS MICRO SS TROCAR POINT","SUP-ITM-10030142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.02","78.45","","456.17","105.33","1284.66","242","83.51","131.02","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","52.78","35.48","309.60","1 through 10","124.68","218.54","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","173.31","173.31","173.31","1 through 10","124.68","218.54","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","175.31","62.5","","26.48","26.48","26.48","1 through 10","124.68","218.54","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","127.34","127.34","127.34","1 through 10","124.68","218.54","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","99.24","60.15","134.68","19","124.68","218.54","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","280.50","210.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.34","59.3","","59.44","59.44","59.44","1 through 10","140.25","220.05","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","239.87","239.87","239.87","1 through 10","140.25","220.05","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","77.27","46.21","95.91","26","140.25","220.05","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","AETNA [1001]","HB CH AETNA HMO / PPO","32.43","58.3","","464.71","67.87","1012.10","221","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","32.43","58.3","","293.04","293.04","293.04","11","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","29.48","53","","983.89","983.89","983.89","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","32.26","58","","677.18","677.18","677.18","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","34.76","62.5","","46.58","46.58","46.58","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","40.60","73","","747.15","747.15","747.15","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.72","44.45","","1141.67","481.21","1141.67","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.72","44.45","","76.54","76.54","76.54","1 through 10","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","WELLPOINT [1015]","HB CH WELLPOINT","43.33","77.91","","273.64","94.28","1367.51","138","24.72","43.33","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.98","59.3","","720.78","230.14","2010.94","427","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","32.98","59.3","","344.45","344.45","344.45","1 through 10","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","43.63","78.45","","1120.13","1120.13","1120.13","1 through 10","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.63","78.45","","456.17","105.33","1284.66","242","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","464.71","67.87","1012.10","221","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","34.98","58.3","","293.04","293.04","293.04","11","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","983.89","983.89","983.89","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","34.80","58","","677.18","677.18","677.18","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37.50","62.5","","46.58","46.58","46.58","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","747.15","747.15","747.15","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","1141.67","481.21","1141.67","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","76.54","76.54","76.54","1 through 10","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","273.64","94.28","1367.51","138","26.67","46.75","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","720.78","230.14","2010.94","427","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","35.58","59.3","","344.45","344.45","344.45","1 through 10","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","1120.13","1120.13","1120.13","1 through 10","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM 100 SS","SUP-ITM-10028333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","456.17","105.33","1284.66","242","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","AETNA [1001]","HB CH AETNA HMO / PPO","45.04","58.3","","52.78","35.48","309.60","1 through 10","34.34","60.19","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","40.94","53","","173.31","173.31","173.31","1 through 10","34.34","60.19","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","48.28","62.5","","26.48","26.48","26.48","1 through 10","34.34","60.19","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.34","44.45","","127.34","127.34","127.34","1 through 10","34.34","60.19","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","WELLPOINT [1015]","HB CH WELLPOINT","60.19","77.91","","99.24","60.15","134.68","19","34.34","60.19","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","77.25","57.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.81","59.3","","59.44","59.44","59.44","1 through 10","38.63","60.6","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","77.25","57.94","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","60.60","78.45","","239.87","239.87","239.87","1 through 10","38.63","60.6","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","77.25","57.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.60","78.45","","77.27","46.21","95.91","26","38.63","60.6","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","464.71","67.87","1012.10","221","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","293.04","293.04","293.04","11","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","983.89","983.89","983.89","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","147.90","58","","677.18","677.18","677.18","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","159.38","62.5","","46.58","46.58","46.58","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","747.15","747.15","747.15","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","1141.67","481.21","1141.67","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","76.54","76.54","76.54","1 through 10","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","273.64","94.28","1367.51","138","113.35","198.67","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","720.78","230.14","2010.94","427","127.5","200.05","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","151.22","59.3","","344.45","344.45","344.45","1 through 10","127.5","200.05","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","1120.13","1120.13","1120.13","1 through 10","127.5","200.05","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM SS FIXATION","SUP-ITM-10100633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","456.17","105.33","1284.66","242","127.5","200.05","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","AETNA [1001]","HB CH AETNA HMO / PPO","590.83","58.3","","464.71","67.87","1012.10","221","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","590.83","58.3","","293.04","293.04","293.04","11","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.12","53","","983.89","983.89","983.89","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","587.79","58","","677.18","677.18","677.18","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","633.39","62.5","","46.58","46.58","46.58","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","747.15","747.15","747.15","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","1141.67","481.21","1141.67","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","76.54","76.54","76.54","1 through 10","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","WELLPOINT [1015]","HB CH WELLPOINT","789.56","77.91","","273.64","94.28","1367.51","138","450.47","789.56","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","600.96","59.3","","720.78","230.14","2010.94","427","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","600.96","59.3","","344.45","344.45","344.45","1 through 10","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","1120.13","1120.13","1120.13","1 through 10","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","456.17","105.33","1284.66","242","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","AETNA [1001]","HB CH AETNA HMO / PPO","21.42","58.3","","464.71","67.87","1012.10","221","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","21.42","58.3","","293.04","293.04","293.04","11","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19.47","53","","983.89","983.89","983.89","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","21.31","58","","677.18","677.18","677.18","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22.96","62.5","","46.58","46.58","46.58","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","26.82","73","","747.15","747.15","747.15","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.33","44.45","","1141.67","481.21","1141.67","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.33","44.45","","76.54","76.54","76.54","1 through 10","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","WELLPOINT [1015]","HB CH WELLPOINT","28.62","77.91","","273.64","94.28","1367.51","138","16.33","28.62","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.79","59.3","","720.78","230.14","2010.94","427","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","21.79","59.3","","344.45","344.45","344.45","1 through 10","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","28.82","78.45","","1120.13","1120.13","1120.13","1 through 10","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.82","78.45","","456.17","105.33","1284.66","242","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","AETNA [1001]","HB CH AETNA HMO / PPO","31.48","58.3","","464.71","67.87","1012.10","221","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.48","58.3","","293.04","293.04","293.04","11","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.62","53","","983.89","983.89","983.89","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","31.32","58","","677.18","677.18","677.18","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33.75","62.5","","46.58","46.58","46.58","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.42","73","","747.15","747.15","747.15","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.00","44.45","","1141.67","481.21","1141.67","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.00","44.45","","76.54","76.54","76.54","1 through 10","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","WELLPOINT [1015]","HB CH WELLPOINT","42.07","77.91","","273.64","94.28","1367.51","138","24","42.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.02","59.3","","720.78","230.14","2010.94","427","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","32.02","59.3","","344.45","344.45","344.45","1 through 10","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","42.36","78.45","","1120.13","1120.13","1120.13","1 through 10","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.36","78.45","","456.17","105.33","1284.66","242","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","AETNA [1001]","HB CH AETNA HMO / PPO","13.59","58.3","","464.71","67.87","1012.10","221","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","13.59","58.3","","293.04","293.04","293.04","11","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","12.35","53","","983.89","983.89","983.89","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13.52","58","","677.18","677.18","677.18","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14.57","62.5","","46.58","46.58","46.58","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17.02","73","","747.15","747.15","747.15","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.36","44.45","","1141.67","481.21","1141.67","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.36","44.45","","76.54","76.54","76.54","1 through 10","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.31","17.48","WELLPOINT [1015]","HB CH WELLPOINT","18.16","77.91","","273.64","94.28","1367.51","138","10.36","18.16","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.31","17.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.82","59.3","","720.78","230.14","2010.94","427","11.66","18.29","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.31","17.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","13.82","59.3","","344.45","344.45","344.45","1 through 10","11.66","18.29","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.31","17.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","18.29","78.45","","1120.13","1120.13","1120.13","1 through 10","11.66","18.29","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.31","17.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.29","78.45","","456.17","105.33","1284.66","242","11.66","18.29","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","AETNA [1001]","HB CH AETNA HMO / PPO","26.22","58.3","","464.71","67.87","1012.10","221","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","26.22","58.3","","293.04","293.04","293.04","11","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23.83","53","","983.89","983.89","983.89","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","26.08","58","","677.18","677.18","677.18","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28.11","62.5","","46.58","46.58","46.58","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32.83","73","","747.15","747.15","747.15","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.99","44.45","","1141.67","481.21","1141.67","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.99","44.45","","76.54","76.54","76.54","1 through 10","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","WELLPOINT [1015]","HB CH WELLPOINT","35.04","77.91","","273.64","94.28","1367.51","138","19.99","35.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.67","59.3","","720.78","230.14","2010.94","427","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","26.67","59.3","","344.45","344.45","344.45","1 through 10","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","35.28","78.45","","1120.13","1120.13","1120.13","1 through 10","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.28","78.45","","456.17","105.33","1284.66","242","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","AETNA [1001]","HB CH AETNA HMO / PPO","10.23","58.3","","464.71","67.87","1012.10","221","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","10.23","58.3","","293.04","293.04","293.04","11","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.30","53","","983.89","983.89","983.89","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10.17","58","","677.18","677.18","677.18","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","10.96","62.5","","46.58","46.58","46.58","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","12.80","73","","747.15","747.15","747.15","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.80","44.45","","1141.67","481.21","1141.67","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.80","44.45","","76.54","76.54","76.54","1 through 10","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","WELLPOINT [1015]","HB CH WELLPOINT","13.67","77.91","","273.64","94.28","1367.51","138","7.8","13.67","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","10.40","59.3","","720.78","230.14","2010.94","427","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","10.40","59.3","","344.45","344.45","344.45","1 through 10","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","13.76","78.45","","1120.13","1120.13","1120.13","1 through 10","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","13.76","78.45","","456.17","105.33","1284.66","242","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","AETNA [1001]","HB CH AETNA HMO / PPO","45.47","58.3","","464.71","67.87","1012.10","221","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.47","58.3","","293.04","293.04","293.04","11","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.34","53","","983.89","983.89","983.89","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","45.24","58","","677.18","677.18","677.18","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","48.75","62.5","","46.58","46.58","46.58","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","747.15","747.15","747.15","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","1141.67","481.21","1141.67","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","76.54","76.54","76.54","1 through 10","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","WELLPOINT [1015]","HB CH WELLPOINT","60.77","77.91","","273.64","94.28","1367.51","138","34.67","60.77","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.25","59.3","","720.78","230.14","2010.94","427","39","61.19","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","46.25","59.3","","344.45","344.45","344.45","1 through 10","39","61.19","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","1120.13","1120.13","1120.13","1 through 10","39","61.19","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","456.17","105.33","1284.66","242","39","61.19","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","AETNA [1001]","HB CH AETNA HMO / PPO","60.08","58.3","","464.71","67.87","1012.10","221","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","60.08","58.3","","293.04","293.04","293.04","11","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.62","53","","983.89","983.89","983.89","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","59.77","58","","677.18","677.18","677.18","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","64.41","62.5","","46.58","46.58","46.58","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.23","73","","747.15","747.15","747.15","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.81","44.45","","1141.67","481.21","1141.67","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.81","44.45","","76.54","76.54","76.54","1 through 10","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","WELLPOINT [1015]","HB CH WELLPOINT","80.29","77.91","","273.64","94.28","1367.51","138","45.81","80.29","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.11","59.3","","720.78","230.14","2010.94","427","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","61.11","59.3","","344.45","344.45","344.45","1 through 10","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","80.84","78.45","","1120.13","1120.13","1120.13","1 through 10","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.84","78.45","","456.17","105.33","1284.66","242","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","52.78","35.48","309.60","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","33.39","53","","173.31","173.31","173.31","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","39.38","62.5","","26.48","26.48","26.48","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","127.34","127.34","127.34","1 through 10","28","49.08","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB CH WELLPOINT","49.08","77.91","","99.24","60.15","134.68","19","28","49.08","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","59.44","59.44","59.44","1 through 10","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","239.87","239.87","239.87","1 through 10","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","77.27","46.21","95.91","26","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","AETNA [1001]","HB CH AETNA HMO / PPO","236.20","58.3","","464.71","67.87","1012.10","221","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","236.20","58.3","","293.04","293.04","293.04","11","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","214.73","53","","983.89","983.89","983.89","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","234.99","58","","677.18","677.18","677.18","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","253.22","62.5","","46.58","46.58","46.58","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","295.76","73","","747.15","747.15","747.15","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.09","44.45","","1141.67","481.21","1141.67","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.09","44.45","","76.54","76.54","76.54","1 through 10","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.15","303.86","WELLPOINT [1015]","HB CH WELLPOINT","315.65","77.91","","273.64","94.28","1367.51","138","180.09","315.65","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.15","303.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.25","59.3","","720.78","230.14","2010.94","427","202.58","317.84","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.15","303.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","240.25","59.3","","344.45","344.45","344.45","1 through 10","202.58","317.84","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.15","303.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","317.84","78.45","","1120.13","1120.13","1120.13","1 through 10","202.58","317.84","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.15","303.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","317.84","78.45","","456.17","105.33","1284.66","242","202.58","317.84","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","AETNA [1001]","HB CH AETNA HMO / PPO","51.49","58.3","","464.71","67.87","1012.10","221","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","51.49","58.3","","293.04","293.04","293.04","11","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.81","53","","983.89","983.89","983.89","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","51.23","58","","677.18","677.18","677.18","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","55.20","62.5","","46.58","46.58","46.58","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","64.47","73","","747.15","747.15","747.15","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.26","44.45","","1141.67","481.21","1141.67","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.26","44.45","","76.54","76.54","76.54","1 through 10","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","WELLPOINT [1015]","HB CH WELLPOINT","68.81","77.91","","273.64","94.28","1367.51","138","39.26","68.81","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.37","59.3","","720.78","230.14","2010.94","427","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","52.37","59.3","","344.45","344.45","344.45","1 through 10","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","69.29","78.45","","1120.13","1120.13","1120.13","1 through 10","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.29","78.45","","456.17","105.33","1284.66","242","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","AETNA [1001]","HB CH AETNA HMO / PPO","10.96","58.3","","464.71","67.87","1012.10","221","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","10.96","58.3","","293.04","293.04","293.04","11","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.96","53","","983.89","983.89","983.89","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10.90","58","","677.18","677.18","677.18","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11.75","62.5","","46.58","46.58","46.58","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","13.72","73","","747.15","747.15","747.15","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.36","44.45","","1141.67","481.21","1141.67","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.36","44.45","","76.54","76.54","76.54","1 through 10","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","both","","","18.80","14.10","WELLPOINT [1015]","HB CH WELLPOINT","14.65","77.91","","273.64","94.28","1367.51","138","8.36","14.65","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18.80","14.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.15","59.3","","720.78","230.14","2010.94","427","9.4","14.75","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18.80","14.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","11.15","59.3","","344.45","344.45","344.45","1 through 10","9.4","14.75","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18.80","14.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","14.75","78.45","","1120.13","1120.13","1120.13","1 through 10","9.4","14.75","percent of total billed charges",""
"K-WIRE BONE 229MM 0.035IN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10124336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18.80","14.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","14.75","78.45","","456.17","105.33","1284.66","242","9.4","14.75","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","AETNA [1001]","HB CH AETNA HMO / PPO","11.52","58.3","","464.71","67.87","1012.10","221","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","11.52","58.3","","293.04","293.04","293.04","11","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10.47","53","","983.89","983.89","983.89","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11.46","58","","677.18","677.18","677.18","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12.35","62.5","","46.58","46.58","46.58","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","14.42","73","","747.15","747.15","747.15","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.78","44.45","","1141.67","481.21","1141.67","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.78","44.45","","76.54","76.54","76.54","1 through 10","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","WELLPOINT [1015]","HB CH WELLPOINT","15.40","77.91","","273.64","94.28","1367.51","138","8.78","15.4","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.72","59.3","","720.78","230.14","2010.94","427","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","11.72","59.3","","344.45","344.45","344.45","1 through 10","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","15.50","78.45","","1120.13","1120.13","1120.13","1 through 10","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","15.50","78.45","","456.17","105.33","1284.66","242","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","AETNA [1001]","HB CH AETNA HMO / PPO","13.27","58.3","","464.71","67.87","1012.10","221","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","13.27","58.3","","293.04","293.04","293.04","11","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","12.06","53","","983.89","983.89","983.89","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13.20","58","","677.18","677.18","677.18","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14.23","62.5","","46.58","46.58","46.58","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.61","73","","747.15","747.15","747.15","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.12","44.45","","1141.67","481.21","1141.67","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.12","44.45","","76.54","76.54","76.54","1 through 10","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","WELLPOINT [1015]","HB CH WELLPOINT","17.73","77.91","","273.64","94.28","1367.51","138","10.12","17.73","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.50","59.3","","720.78","230.14","2010.94","427","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","13.50","59.3","","344.45","344.45","344.45","1 through 10","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","17.86","78.45","","1120.13","1120.13","1120.13","1 through 10","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.86","78.45","","456.17","105.33","1284.66","242","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","AETNA [1001]","HB CH AETNA HMO / PPO","43.10","58.3","","464.71","67.87","1012.10","221","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.10","58.3","","293.04","293.04","293.04","11","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.18","53","","983.89","983.89","983.89","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","42.87","58","","677.18","677.18","677.18","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.20","62.5","","46.58","46.58","46.58","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","53.96","73","","747.15","747.15","747.15","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.86","44.45","","1141.67","481.21","1141.67","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.86","44.45","","76.54","76.54","76.54","1 through 10","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","WELLPOINT [1015]","HB CH WELLPOINT","57.59","77.91","","273.64","94.28","1367.51","138","32.86","57.59","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.83","59.3","","720.78","230.14","2010.94","427","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","43.83","59.3","","344.45","344.45","344.45","1 through 10","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","57.99","78.45","","1120.13","1120.13","1120.13","1 through 10","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.99","78.45","","456.17","105.33","1284.66","242","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","AETNA [1001]","HB CH AETNA HMO / PPO","45.33","58.3","","464.71","67.87","1012.10","221","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.33","58.3","","293.04","293.04","293.04","11","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.21","53","","983.89","983.89","983.89","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","45.10","58","","677.18","677.18","677.18","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","48.60","62.5","","46.58","46.58","46.58","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.76","73","","747.15","747.15","747.15","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.56","44.45","","1141.67","481.21","1141.67","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.56","44.45","","76.54","76.54","76.54","1 through 10","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","WELLPOINT [1015]","HB CH WELLPOINT","60.58","77.91","","273.64","94.28","1367.51","138","34.56","60.58","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.11","59.3","","720.78","230.14","2010.94","427","38.88","61","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","46.11","59.3","","344.45","344.45","344.45","1 through 10","38.88","61","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","61.00","78.45","","1120.13","1120.13","1120.13","1 through 10","38.88","61","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.00","78.45","","456.17","105.33","1284.66","242","38.88","61","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","AETNA [1001]","HB CH AETNA HMO / PPO","348.28","58.3","","464.71","67.87","1012.10","221","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","348.28","58.3","","293.04","293.04","293.04","11","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","316.62","53","","983.89","983.89","983.89","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","346.49","58","","677.18","677.18","677.18","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","373.37","62.5","","46.58","46.58","46.58","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","436.09","73","","747.15","747.15","747.15","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.54","44.45","","1141.67","481.21","1141.67","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.54","44.45","","76.54","76.54","76.54","1 through 10","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","WELLPOINT [1015]","HB CH WELLPOINT","465.43","77.91","","273.64","94.28","1367.51","138","265.54","465.43","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","354.25","59.3","","720.78","230.14","2010.94","427","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","354.25","59.3","","344.45","344.45","344.45","1 through 10","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","468.65","78.45","","1120.13","1120.13","1120.13","1 through 10","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","468.65","78.45","","456.17","105.33","1284.66","242","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","AETNA [1001]","HB CH AETNA HMO / PPO","7.44","58.3","","464.71","67.87","1012.10","221","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7.44","58.3","","293.04","293.04","293.04","11","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.76","53","","983.89","983.89","983.89","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7.40","58","","677.18","677.18","677.18","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7.98","62.5","","46.58","46.58","46.58","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9.31","73","","747.15","747.15","747.15","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.67","44.45","","1141.67","481.21","1141.67","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.67","44.45","","76.54","76.54","76.54","1 through 10","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","12.76","9.57","WELLPOINT [1015]","HB CH WELLPOINT","9.94","77.91","","273.64","94.28","1367.51","138","5.67","9.94","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.76","9.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","7.57","59.3","","720.78","230.14","2010.94","427","6.38","10.01","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.76","9.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7.57","59.3","","344.45","344.45","344.45","1 through 10","6.38","10.01","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.76","9.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","10.01","78.45","","1120.13","1120.13","1120.13","1 through 10","6.38","10.01","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12.76","9.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10.01","78.45","","456.17","105.33","1284.66","242","6.38","10.01","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","AETNA [1001]","HB CH AETNA HMO / PPO","6.93","58.3","","464.71","67.87","1012.10","221","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6.93","58.3","","293.04","293.04","293.04","11","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.30","53","","983.89","983.89","983.89","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6.90","58","","677.18","677.18","677.18","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7.43","62.5","","46.58","46.58","46.58","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8.68","73","","747.15","747.15","747.15","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.29","44.45","","1141.67","481.21","1141.67","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.29","44.45","","76.54","76.54","76.54","1 through 10","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.89","8.92","WELLPOINT [1015]","HB CH WELLPOINT","9.26","77.91","","273.64","94.28","1367.51","138","5.29","9.26","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.89","8.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","7.05","59.3","","720.78","230.14","2010.94","427","5.95","9.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.89","8.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7.05","59.3","","344.45","344.45","344.45","1 through 10","5.95","9.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.89","8.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","9.33","78.45","","1120.13","1120.13","1120.13","1 through 10","5.95","9.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.89","8.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9.33","78.45","","456.17","105.33","1284.66","242","5.95","9.33","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","464.71","67.87","1012.10","221","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","293.04","293.04","293.04","11","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","983.89","983.89","983.89","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.60","58","","677.18","677.18","677.18","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.00","62.5","","46.58","46.58","46.58","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","747.15","747.15","747.15","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","1141.67","481.21","1141.67","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","76.54","76.54","76.54","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","273.64","94.28","1367.51","138","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","720.78","230.14","2010.94","427","60","94.14","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","71.16","59.3","","344.45","344.45","344.45","1 through 10","60","94.14","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","1120.13","1120.13","1120.13","1 through 10","60","94.14","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","456.17","105.33","1284.66","242","60","94.14","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.84","58.3","","464.71","67.87","1012.10","221","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.84","58.3","","293.04","293.04","293.04","11","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.58","53","","983.89","983.89","983.89","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","46.60","58","","677.18","677.18","677.18","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","50.21","62.5","","46.58","46.58","46.58","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","747.15","747.15","747.15","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","1141.67","481.21","1141.67","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","76.54","76.54","76.54","1 through 10","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","WELLPOINT [1015]","HB CH WELLPOINT","62.59","77.91","","273.64","94.28","1367.51","138","35.71","62.59","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.64","59.3","","720.78","230.14","2010.94","427","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","47.64","59.3","","344.45","344.45","344.45","1 through 10","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","1120.13","1120.13","1120.13","1 through 10","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","456.17","105.33","1284.66","242","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","AETNA [1001]","HB CH AETNA HMO / PPO","4.06","58.3","","464.71","67.87","1012.10","221","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4.06","58.3","","293.04","293.04","293.04","11","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3.69","53","","983.89","983.89","983.89","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4.04","58","","677.18","677.18","677.18","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4.35","62.5","","46.58","46.58","46.58","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5.08","73","","747.15","747.15","747.15","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.09","44.45","","1141.67","481.21","1141.67","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.09","44.45","","76.54","76.54","76.54","1 through 10","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","WELLPOINT [1015]","HB CH WELLPOINT","5.42","77.91","","273.64","94.28","1367.51","138","3.09","5.42","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","4.13","59.3","","720.78","230.14","2010.94","427","3.48","5.46","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4.13","59.3","","344.45","344.45","344.45","1 through 10","3.48","5.46","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5.46","78.45","","1120.13","1120.13","1120.13","1 through 10","3.48","5.46","percent of total billed charges",""
"K-WIRE BONE 9IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5.46","78.45","","456.17","105.33","1284.66","242","3.48","5.46","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","464.71","67.87","1012.10","221","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","293.04","293.04","293.04","11","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","983.89","983.89","983.89","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.60","58","","677.18","677.18","677.18","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.00","62.5","","46.58","46.58","46.58","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","747.15","747.15","747.15","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","1141.67","481.21","1141.67","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","76.54","76.54","76.54","1 through 10","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","273.64","94.28","1367.51","138","53.34","93.49","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","720.78","230.14","2010.94","427","60","94.14","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","71.16","59.3","","344.45","344.45","344.45","1 through 10","60","94.14","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","1120.13","1120.13","1120.13","1 through 10","60","94.14","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","456.17","105.33","1284.66","242","60","94.14","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","AETNA [1001]","HB CH AETNA HMO / PPO","6.60","58.3","","464.71","67.87","1012.10","221","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6.60","58.3","","293.04","293.04","293.04","11","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.00","53","","983.89","983.89","983.89","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6.57","58","","677.18","677.18","677.18","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7.08","62.5","","46.58","46.58","46.58","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8.26","73","","747.15","747.15","747.15","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.03","44.45","","1141.67","481.21","1141.67","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.03","44.45","","76.54","76.54","76.54","1 through 10","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","11.32","8.49","WELLPOINT [1015]","HB CH WELLPOINT","8.82","77.91","","273.64","94.28","1367.51","138","5.03","8.82","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.32","8.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","6.71","59.3","","720.78","230.14","2010.94","427","5.66","8.88","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.32","8.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","6.71","59.3","","344.45","344.45","344.45","1 through 10","5.66","8.88","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.32","8.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","8.88","78.45","","1120.13","1120.13","1120.13","1 through 10","5.66","8.88","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11.32","8.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8.88","78.45","","456.17","105.33","1284.66","242","5.66","8.88","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","AETNA [1001]","HB CH AETNA HMO / PPO","372.62","58.3","","464.71","67.87","1012.10","221","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","372.62","58.3","","293.04","293.04","293.04","11","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","338.75","53","","983.89","983.89","983.89","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","370.71","58","","677.18","677.18","677.18","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","399.47","62.5","","46.58","46.58","46.58","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","466.58","73","","747.15","747.15","747.15","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.10","44.45","","1141.67","481.21","1141.67","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.10","44.45","","76.54","76.54","76.54","1 through 10","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","WELLPOINT [1015]","HB CH WELLPOINT","497.96","77.91","","273.64","94.28","1367.51","138","284.1","497.96","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","379.02","59.3","","720.78","230.14","2010.94","427","319.58","501.41","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","379.02","59.3","","344.45","344.45","344.45","1 through 10","319.58","501.41","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","501.41","78.45","","1120.13","1120.13","1120.13","1 through 10","319.58","501.41","percent of total billed charges",""
"K-WIRE L 65X1.2MM SMOOTH TROCAR TIP FOOT ANKLE ANCHORAGE IMPLANTABLE","SUP-ITM-10082665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","501.41","78.45","","456.17","105.33","1284.66","242","319.58","501.41","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","AETNA [1001]","HB CH AETNA HMO / PPO","40.40","58.3","","464.71","67.87","1012.10","221","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","40.40","58.3","","293.04","293.04","293.04","11","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","36.73","53","","983.89","983.89","983.89","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","40.19","58","","677.18","677.18","677.18","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","43.31","62.5","","46.58","46.58","46.58","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","50.59","73","","747.15","747.15","747.15","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.80","44.45","","1141.67","481.21","1141.67","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.80","44.45","","76.54","76.54","76.54","1 through 10","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","WELLPOINT [1015]","HB CH WELLPOINT","53.99","77.91","","273.64","94.28","1367.51","138","30.8","53.99","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","41.09","59.3","","720.78","230.14","2010.94","427","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","41.09","59.3","","344.45","344.45","344.45","1 through 10","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","54.37","78.45","","1120.13","1120.13","1120.13","1 through 10","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","54.37","78.45","","456.17","105.33","1284.66","242","34.65","54.37","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","AETNA [1001]","HB CH AETNA HMO / PPO","33.58","58.3","","52.78","35.48","309.60","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.53","53","","173.31","173.31","173.31","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","36.00","62.5","","26.48","26.48","26.48","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.60","44.45","","127.34","127.34","127.34","1 through 10","25.6","44.88","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","WELLPOINT [1015]","HB CH WELLPOINT","44.88","77.91","","99.24","60.15","134.68","19","25.6","44.88","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.60","43.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.16","59.3","","59.44","59.44","59.44","1 through 10","28.8","45.19","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","239.87","239.87","239.87","1 through 10","28.8","45.19","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","77.27","46.21","95.91","26","28.8","45.19","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","464.71","67.87","1012.10","221","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","293.04","293.04","293.04","11","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","983.89","983.89","983.89","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","677.18","677.18","677.18","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","46.58","46.58","46.58","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","747.15","747.15","747.15","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1141.67","481.21","1141.67","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","76.54","76.54","76.54","1 through 10","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","273.64","94.28","1367.51","138","66.68","116.87","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","720.78","230.14","2010.94","427","75","117.68","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","344.45","344.45","344.45","1 through 10","75","117.68","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1120.13","1120.13","1120.13","1 through 10","75","117.68","percent of total billed charges",""
"K-WIRE THREADED 3.2MM SHORT PK/2EA","SUP-ITM-10310339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","456.17","105.33","1284.66","242","75","117.68","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","AETNA [1001]","HB CH AETNA HMO / PPO","1.85","58.3","","0.76","0.40","5.05","171","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","0.31","","APC Price ($0.30). Final payment is multiplied by 103%.","0.52","0.36","0.78","32","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","0.30","","APC Price ($0.30).","0.49","0.34","0.74","38","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2.31","73","","4.92","4.92","4.92","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1.85","58.3","","0.53","0.53","0.53","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1.68","53","","1.99","0.98","1.99","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","MEDICARE [2001]","HB NWH MEDICARE","0.30","","APC Price ($0.30).","0.75","0.75","2.25","160","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","MOLINA [1014]","HB NWH MEDICARE","0.30","","APC Price ($0.30).","1.37","0.69","1.37","16","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2.31","73","","1.57","1.57","1.57","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","TRICARE [160005]","HB NWH TRICARE","0.33","","APC Price ($0.35). Final payment is multiplied by 95%.","1.50","0.50","2.50","30","0.3","2.31","other","Tricare OPPS"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","0.30","","APC Price ($0.30). Final payment is multiplied by 98%.","2.22","0.49","3.69","84","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","0.30","","APC Price ($0.30). Final payment is multiplied by 98%.","0.74","0.35","1.48","218","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.17","2.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","1.65","52.2","","1.77","0.48","3.04","181","0.52","1.65","percent of total billed charges",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","59667.70","44750.77","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","16330.64","","Case rate ($15,854.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,287.38, add-ons for qualifying new technology services are included. If operating cost exceeds $61,429.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,153.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $14,643.36. The transfer operating threshold is the transfer adjustment factor * $16,287.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.62. The transfer capital threshold is the transfer adjustment factor * $1,211.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16382.47","16382.47","16382.47","1 through 10","15537.89","18078.0809","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","59667.70","44750.77","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15854.99","","Case rate ($15,854.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,287.38, add-ons for qualifying new technology services are included. If operating cost exceeds $61,429.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,153.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $14,643.36. The transfer operating threshold is the transfer adjustment factor * $16,287.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.62. The transfer capital threshold is the transfer adjustment factor * $1,211.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15764.55","15764.55","15764.55","1 through 10","15537.89","18078.0809","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","59667.70","44750.77","MEDICARE [2001]","HB NWH MEDICARE","15854.99","","Case rate ($15,854.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,287.38, add-ons for qualifying new technology services are included. If operating cost exceeds $61,429.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,153.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $14,643.36. The transfer operating threshold is the transfer adjustment factor * $16,287.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.62. The transfer capital threshold is the transfer adjustment factor * $1,211.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17479.05","17447.68","17479.05","1 through 10","15537.89","18078.0809","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","42131.98","31598.98","MEDICARE [2001]","HB NWH MEDICARE","13444.68","","Case rate ($13,444.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,811.34, add-ons for qualifying new technology services are included. If operating cost exceeds $58,953.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,969.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $12,417.25. The transfer operating threshold is the transfer adjustment factor * $13,811.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.43. The transfer capital threshold is the transfer adjustment factor * $1,027.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14354.43","14354.43","14354.43","1 through 10","13175.79","14873.056","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","32702.22","24526.66","MEDICARE [2001]","HB NWH MEDICARE","12590.78","","Case rate ($12,590.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,763.40, add-ons for qualifying new technology services are included. If operating cost exceeds $56,905.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,817.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,715.70. The transfer operating threshold is the transfer adjustment factor * $11,763.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.08. The transfer capital threshold is the transfer adjustment factor * $875.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12789.18","12789.01","12812.17","18","11222.09","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","32702.22","24526.66","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11222.09","","Case rate ($11,451.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,763.40, add-ons for qualifying new technology services are included. If operating cost exceeds $56,905.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,817.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,576.03. The transfer operating threshold is the transfer adjustment factor * $11,763.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.08. The transfer capital threshold is the transfer adjustment factor * $875.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11427.89","11427.89","11427.89","1 through 10","11222.09","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","32702.22","24526.66","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","11222.09","","Case rate ($11,451.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,763.40, add-ons for qualifying new technology services are included. If operating cost exceeds $56,905.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,817.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,576.03. The transfer operating threshold is the transfer adjustment factor * $11,763.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.08. The transfer capital threshold is the transfer adjustment factor * $875.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12963.43","12963.43","12963.43","1 through 10","11222.09","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","42186.37","31639.78","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","22674.60","","Case rate ($22,014.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,614.53, add-ons for qualifying new technology services are included. If operating cost exceeds $67,756.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,624.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,331.87. The transfer operating threshold is the transfer adjustment factor * $22,614.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.30. The transfer capital threshold is the transfer adjustment factor * $1,682.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11986.15","11986.15","11986.15","1 through 10","21573.89","25556.1427","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","42186.37","31639.78","FALLON HEALTH [1008]","HB NWH MEDICARE","22014.17","","Case rate ($22,014.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,614.53, add-ons for qualifying new technology services are included. If operating cost exceeds $67,756.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,624.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,331.87. The transfer operating threshold is the transfer adjustment factor * $22,614.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.30. The transfer capital threshold is the transfer adjustment factor * $1,682.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26683.20","26683.20","26683.20","1 through 10","21573.89","25556.1427","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","42186.37","31639.78","MEDICARE [2001]","HB NWH MEDICARE","22014.17","","Case rate ($22,014.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,614.53, add-ons for qualifying new technology services are included. If operating cost exceeds $67,756.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,624.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,331.87. The transfer operating threshold is the transfer adjustment factor * $22,614.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.30. The transfer capital threshold is the transfer adjustment factor * $1,682.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24665.01","12779.65","24709.35","1 through 10","21573.89","25556.1427","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","42186.37","31639.78","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","21573.89","","Case rate ($22,014.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,614.53, add-ons for qualifying new technology services are included. If operating cost exceeds $67,756.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,624.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,331.87. The transfer operating threshold is the transfer adjustment factor * $22,614.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.30. The transfer capital threshold is the transfer adjustment factor * $1,682.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19022.68","19022.68","19022.68","1 through 10","21573.89","25556.1427","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","42186.37","31639.78","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","21573.89","","Case rate ($22,014.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,614.53, add-ons for qualifying new technology services are included. If operating cost exceeds $67,756.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,624.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,331.87. The transfer operating threshold is the transfer adjustment factor * $22,614.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.30. The transfer capital threshold is the transfer adjustment factor * $1,682.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22042.98","22042.98","22042.98","1 through 10","21573.89","25556.1427","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","24274.67","18206.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8970.63","","Case rate ($8,970.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,215.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,357.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,627.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,285.10. The transfer operating threshold is the transfer adjustment factor * $9,215.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $685.53. The transfer capital threshold is the transfer adjustment factor * $685.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8855.51","8855.51","8855.51","1 through 10","8791.22","10152.0474","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","24274.67","18206.00","MEDICARE [2001]","HB NWH MEDICARE","8970.63","","Case rate ($8,970.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,215.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,357.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,627.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,285.10. The transfer operating threshold is the transfer adjustment factor * $9,215.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $685.53. The transfer capital threshold is the transfer adjustment factor * $685.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9798.05","1194.19","9815.65","15","8791.22","10152.0474","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","24274.67","18206.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8791.22","","Case rate ($8,970.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,215.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,357.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,627.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,285.10. The transfer operating threshold is the transfer adjustment factor * $9,215.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $685.53. The transfer capital threshold is the transfer adjustment factor * $685.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8753.31","8753.31","8757.66","1 through 10","8791.22","10152.0474","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","27538.51","20653.88","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","10354.33","","Case rate ($10,052.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,326.91, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,710.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,284.53. The transfer operating threshold is the transfer adjustment factor * $10,326.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.22. The transfer capital threshold is the transfer adjustment factor * $768.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10505.78","10486.06","10521.73","1 through 10","9851.7","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","27538.51","20653.88","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","11053.25","","Case rate ($11,053.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,326.91, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,710.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,285.03. The transfer operating threshold is the transfer adjustment factor * $10,326.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.22. The transfer capital threshold is the transfer adjustment factor * $768.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10092.03","10092.03","11010.59","1 through 10","9851.7","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","27538.51","20653.88","MEDICARE [2001]","HB NWH MEDICARE","11053.25","","Case rate ($11,053.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,326.91, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,710.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,285.03. The transfer operating threshold is the transfer adjustment factor * $10,326.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.22. The transfer capital threshold is the transfer adjustment factor * $768.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11169.54","8818.25","11189.62","94","9851.7","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","27538.51","20653.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9851.70","","Case rate ($10,052.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,326.91, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,710.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,284.53. The transfer operating threshold is the transfer adjustment factor * $10,326.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.22. The transfer capital threshold is the transfer adjustment factor * $768.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9984.58","9981.55","11310.39","1 through 10","9851.7","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","27538.51","20653.88","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9851.70","","Case rate ($10,052.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,326.91, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,710.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,284.53. The transfer operating threshold is the transfer adjustment factor * $10,326.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $768.22. The transfer capital threshold is the transfer adjustment factor * $768.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9975.55","7877.71","10015.05","1 through 10","9851.7","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","20970.55","15727.91","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7711.46","","Case rate ($7,711.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,204.71, add-ons for qualifying new technology services are included. If operating cost exceeds $52,346.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,477.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,175.50. The transfer operating threshold is the transfer adjustment factor * $7,204.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.96. The transfer capital threshold is the transfer adjustment factor * $535.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6921.19","6921.19","6921.19","1 through 10","6873.18","7936.9114","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","20970.55","15727.91","ELDER SERVICES [1037]","HB NWH MEDICARE","7711.46","","Case rate ($7,711.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,204.71, add-ons for qualifying new technology services are included. If operating cost exceeds $52,346.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,477.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,175.50. The transfer operating threshold is the transfer adjustment factor * $7,204.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.96. The transfer capital threshold is the transfer adjustment factor * $535.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6983.05","6983.05","6983.05","1 through 10","6873.18","7936.9114","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","20970.55","15727.91","MEDICARE [2001]","HB NWH MEDICARE","7711.46","","Case rate ($7,711.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,204.71, add-ons for qualifying new technology services are included. If operating cost exceeds $52,346.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,477.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,175.50. The transfer operating threshold is the transfer adjustment factor * $7,204.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.96. The transfer capital threshold is the transfer adjustment factor * $535.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7660.15","1033.09","7673.93","89","6873.18","7936.9114","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","20970.55","15727.91","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6873.18","","Case rate ($7,013.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,204.71, add-ons for qualifying new technology services are included. If operating cost exceeds $52,346.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,477.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,477.49. The transfer operating threshold is the transfer adjustment factor * $7,204.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.96. The transfer capital threshold is the transfer adjustment factor * $535.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6853.30","6845.30","7826.18","1 through 10","6873.18","7936.9114","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","20970.55","15727.91","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6873.18","","Case rate ($7,013.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,204.71, add-ons for qualifying new technology services are included. If operating cost exceeds $52,346.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,477.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,477.49. The transfer operating threshold is the transfer adjustment factor * $7,204.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.96. The transfer capital threshold is the transfer adjustment factor * $535.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6843.39","6843.39","11807.32","1 through 10","6873.18","7936.9114","other","Inpatient DRG"
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","20728.23","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9905.8398","","Fee schedule rate ($38,955.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9905.8398","37454.00","37454.00","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18981.96","","Standard inlier is a Case rate ($18,981.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,120, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,694.56) for the length of stay and the standard reimbursement.","18981.96","18981.96","18981.96","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20390.42","","Standard inlier is a Case rate ($20,390.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,120, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,894.33) for the length of stay and the standard reimbursement.","20390.41","20390.41","20390.41","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9905.8398","","Fee schedule rate ($19,104.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9905.8398","30972.12","30972.12","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","MASSHEALTH [3001]","HB NWH MEDICAID","7914.31","","Case rate ($8,526.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,956.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10695.01","10695.01","10695.01","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","7914.31","","Case rate ($8,526.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,956.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8548.35","8548.35","8548.35","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27213.83","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7914.31","","Case rate ($8,526.42). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,956.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8548.35","8548.35","8548.35","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11247.48","","Standard inlier is a Case rate ($11,247.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,185, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,596.62) for the length of stay and the standard reimbursement.","10736.37","10736.37","10736.37","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12082.04","","Standard inlier is a Case rate ($12,082.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,185, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,714.99) for the length of stay and the standard reimbursement.","12082.03","11532.85","12082.03","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10401.0811","","Fee schedule rate ($11,144.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10401.0811","12606.20","12606.20","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","MASSHEALTH [3001]","HB NWH MEDICAID","4162.78","","Case rate ($4,484.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,914.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4496.27","4496.27","5620.34","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","10215.98","","Fee schedule rate ($10,215.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12018.94","12018.94","12018.94","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","18469.66","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4162.78","","Case rate ($4,484.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,914.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4496.27","4496.27","4496.27","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14135.35","","Standard inlier is a Case rate ($14,135.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,006.57) for the length of stay and the standard reimbursement.","13493.01","13493.01","31085.81","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15184.18","","Standard inlier is a Case rate ($15,184.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,155.33) for the length of stay and the standard reimbursement.","14493.99","15184.18","15184.18","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9905.8398","","Fee schedule rate ($12,487.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9905.8398","18368.12","18368.12","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10401.0811","","Fee schedule rate ($13,111.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10401.0811","13111.64","13111.64","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","13735.94","","Fee schedule rate ($13,735.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13735.94","13735.94","13735.94","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","MASSHEALTH [3001]","HB NWH MEDICAID","5227.47","","Case rate ($5,631.77). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,061.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5862.25","5646.25","8548.34","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6911.64","","Fee schedule rate ($6,911.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6911.64","6911.64","6911.64","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14731.82","","Fee schedule rate ($14,731.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14731.82","14731.82","14731.82","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","20146.35","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5227.47","","Case rate ($5,631.77). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,061.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5646.25","5646.25","5646.25","1 through 10","4074.1","64275.19","case rate",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","28069.05","21051.79","MEDICARE [2001]","HB NWH MEDICARE","9078.06","","Case rate ($9,078.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,325.63, add-ons for qualifying new technology services are included. If operating cost exceeds $54,467.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,635.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,384.33. The transfer operating threshold is the transfer adjustment factor * $9,325.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.74. The transfer capital threshold is the transfer adjustment factor * $693.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","978.30","978.30","978.30","1 through 10","8896.5","10336.9717","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","28069.05","21051.79","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8896.50","","Case rate ($9,078.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,325.63, add-ons for qualifying new technology services are included. If operating cost exceeds $54,467.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,635.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,384.33. The transfer operating threshold is the transfer adjustment factor * $9,325.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.74. The transfer capital threshold is the transfer adjustment factor * $693.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8978.64","8978.64","8978.64","1 through 10","8896.5","10336.9717","other","Inpatient DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","30230.76","22673.07","MEDICARE [2001]","HB NWH MEDICARE","17182.41","","Case rate ($17,182.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,053.30, add-ons for qualifying new technology services are included. If operating cost exceeds $61,195.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,136.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,988.20. The transfer operating threshold is the transfer adjustment factor * $16,053.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,194.21. The transfer capital threshold is the transfer adjustment factor * $1,194.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18029.79","18029.79","18029.79","1 through 10","15314.58","18514.98","other","Inpatient DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","30230.76","22673.07","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15314.58","","Case rate ($15,627.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,053.30, add-ons for qualifying new technology services are included. If operating cost exceeds $61,195.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,136.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,432.91. The transfer operating threshold is the transfer adjustment factor * $16,053.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,194.21. The transfer capital threshold is the transfer adjustment factor * $1,194.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16105.16","16105.16","16105.16","1 through 10","15314.58","18514.98","other","Inpatient DRG"
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","47709.43","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","38608.67","","Standard inlier is a Case rate ($38,608.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $51,256, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,480.65) for the length of stay and the standard reimbursement.","36854.23","36854.23","36854.23","1 through 10","10746.24","91769.65","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","47709.43","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","41473.42","","Standard inlier is a Case rate ($41,473.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $51,256, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,886.98) for the length of stay and the standard reimbursement.","41473.41","41473.41","41473.41","1 through 10","10746.24","91769.65","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","47709.43","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","39201.23","","Fee schedule rate ($39,201.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39201.23","39201.23","39201.23","1 through 10","10746.24","91769.65","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,EXTREME","443","DRG","","","","","","","","inpatient","","","76561.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","85783.01","","Standard inlier is a Case rate ($85,783.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $93,572, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,176.54) for the length of stay and the standard reimbursement.","85783.00","85783.00","85783.00","1 through 10","5227.47","85783.01","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,EXTREME","443","DRG","","","","","","","","inpatient","","","76561.62","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","51837.60","","Fee schedule rate ($51,837.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","118343.36","118343.36","118343.36","1 through 10","5227.47","85783.01","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","20707.09","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","21638.8566","","Fee schedule rate ($40,057.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21638.8566","47125.54","47125.54","1 through 10","5227.47","85783.01","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","45701.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22919.04","","Fee schedule rate ($22,919.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22919.04","22919.04","22919.04","1 through 10","5227.47","85783.01","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","25244.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15184.18","","Standard inlier is a Case rate ($15,184.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,155.33) for the length of stay and the standard reimbursement.","34808.28","34808.28","34808.28","1 through 10","5227.47","85783.01","case rate",""
"Kidney And Urinary Tract Signs And Symptoms With McC","695","MS-DRG","","","","","","","","inpatient","","","33389.17","25041.88","MEDICARE [2001]","HB NWH MEDICARE","9909.79","","Case rate ($9,909.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,180.05, add-ons for qualifying new technology services are included. If operating cost exceeds $55,322.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,699.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,152.50. The transfer operating threshold is the transfer adjustment factor * $10,180.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.30. The transfer capital threshold is the transfer adjustment factor * $757.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10783.27","10783.27","10783.27","1 through 10","9711.59","11152.8142","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","19588.52","14691.39","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6563.55","","Case rate ($6,563.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,132.24, add-ons for qualifying new technology services are included. If operating cost exceeds $51,274.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,398.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,107.37. The transfer operating threshold is the transfer adjustment factor * $6,132.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $456.18. The transfer capital threshold is the transfer adjustment factor * $456.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5965.63","5965.63","5965.63","1 through 10","5850.05","6841.2102","other","Inpatient DRG"
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","AETNA [1001]","HB CH AETNA HMO / PPO","26235.00","58.3","","2190.90","412.50","9264.59","16","20002.5","35059.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","26100.00","58","","1903.20","1903.20","3826.66","1 through 10","20002.5","35059.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28125.00","62.5","","2186.25","2186.25","2186.25","32","20002.5","35059.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32850.00","73","","5556.60","5556.60","5556.60","1 through 10","20002.5","35059.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","WELLPOINT [1015]","HB CH WELLPOINT","35059.50","77.91","","1955.15","885.83","3150.40","26","20002.5","35059.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","45000.00","33750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26685.00","59.3","","831.03","253.22","2394.88","18","22500","35302.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","45000.00","33750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35302.50","78.45","","2481.69","1563.74","8149.28","1 through 10","22500","35302.5","percent of total billed charges",""
"KIT 1.5CC GRAFT BONE AUGMENT SYNTHETIC BIOABSORBABLE","SUP-ITM-10158666","CDM","C1734","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2596.50","57.7","","7655.92","2713.50","7655.92","1 through 10","2385","4279.5","percent of total billed charges",""
"KIT 1.5CC GRAFT BONE AUGMENT SYNTHETIC BIOABSORBABLE","SUP-ITM-10158666","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","3891.04","3891.04","3891.04","1 through 10","2000.25","3530.25","percent of total billed charges",""
"KIT 1.5CC GRAFT BONE AUGMENT SYNTHETIC BIOABSORBABLE","SUP-ITM-10158666","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2596.50","57.7","","7655.92","2713.50","7655.92","1 through 10","2000.25","3530.25","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","AETNA [1001]","HB CH AETNA HMO / PPO","4287.50","58.3","","1530.90","1160.93","1884.08","89","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3897.73","53","","5253.92","5253.92","5253.92","1 through 10","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4265.44","58","","12181.47","12181.47","12181.47","1 through 10","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4596.38","62.5","","1350.68","1350.68","1350.68","1 through 10","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3268.94","44.45","","1910.74","891.94","1910.74","1 through 10","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","7354.20","5515.65","WELLPOINT [1015]","HB CH WELLPOINT","5729.66","77.91","","1829.79","1561.50","2617.12","88","3268.94","5729.66","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7354.20","5515.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","4361.04","59.3","","1359.46","1201.30","1689.00","61","3677.1","5769.37","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7354.20","5515.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4361.04","59.3","","1718.92","1718.92","1718.92","1 through 10","3677.1","5769.37","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7354.20","5515.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5769.37","78.45","","1910.74","1019.06","2344.84","74","3677.1","5769.37","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","AETNA [1001]","HB CH AETNA HMO / PPO","820.28","58.3","","1530.90","1160.93","1884.08","89","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","745.71","53","","5253.92","5253.92","5253.92","1 through 10","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","816.06","58","","12181.47","12181.47","12181.47","1 through 10","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","879.38","62.5","","1350.68","1350.68","1350.68","1 through 10","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.41","44.45","","1910.74","891.94","1910.74","1 through 10","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","WELLPOINT [1015]","HB CH WELLPOINT","1096.19","77.91","","1829.79","1561.50","2617.12","88","625.41","1096.19","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","834.35","59.3","","1359.46","1201.30","1689.00","61","703.5","1103.79","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","834.35","59.3","","1718.92","1718.92","1718.92","1 through 10","703.5","1103.79","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1103.79","78.45","","1910.74","1019.06","2344.84","74","703.5","1103.79","percent of total billed charges",""
"KIT BONE 3CC GRAFT AUGMENT INJECTABLE","SUP-ITM-10239256","CDM","C1734","HCPCS","0278","RC","","","","both","","","6640.00","4980.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3831.28","57.7","","7655.92","2713.50","7655.92","1 through 10","3519.2","6314.64","percent of total billed charges",""
"KIT BONE 3CC GRAFT AUGMENT INJECTABLE","SUP-ITM-10239256","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","6640.00","4980.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3937.52","59.3","","3891.04","3891.04","3891.04","1 through 10","2951.48","5209.08","percent of total billed charges",""
"KIT BONE 3CC GRAFT AUGMENT INJECTABLE","SUP-ITM-10239256","CDM","C1734","HCPCS","0278","RC","","","","outpatient","","","6640.00","4980.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3831.28","57.7","","7655.92","2713.50","7655.92","1 through 10","2951.48","5209.08","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","AETNA [1001]","HB CH AETNA HMO / PPO","4065.84","58.3","","2190.90","412.50","9264.59","16","3099.94","5433.44","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4044.92","58","","1903.20","1903.20","3826.66","1 through 10","3099.94","5433.44","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4358.75","62.5","","2186.25","2186.25","2186.25","32","3099.94","5433.44","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5091.02","73","","5556.60","5556.60","5556.60","1 through 10","3099.94","5433.44","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","WELLPOINT [1015]","HB CH WELLPOINT","5433.44","77.91","","1955.15","885.83","3150.40","26","3099.94","5433.44","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6974.00","5230.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4135.58","59.3","","831.03","253.22","2394.88","18","3487","5471.1","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133160","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5471.10","78.45","","2481.69","1563.74","8149.28","1 through 10","3487","5471.1","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","464.71","67.87","1012.10","221","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2404.88","58.3","","293.04","293.04","293.04","11","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","983.89","983.89","983.89","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2392.50","58","","677.18","677.18","677.18","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2578.13","62.5","","46.58","46.58","46.58","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","747.15","747.15","747.15","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1141.67","481.21","1141.67","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","76.54","76.54","76.54","1 through 10","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","273.64","94.28","1367.51","138","1833.56","3213.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","720.78","230.14","2010.94","427","2062.5","3236.06","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2446.13","59.3","","344.45","344.45","344.45","1 through 10","2062.5","3236.06","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","1120.13","1120.13","1120.13","1 through 10","2062.5","3236.06","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","456.17","105.33","1284.66","242","2062.5","3236.06","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","1778.28","1333.71","AETNA [1001]","HB CH AETNA HMO / PPO","1036.74","58.3","","34.87","34.02","34.87","1 through 10","790.45","1385.46","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","1778.28","1333.71","WELLPOINT [1015]","HB CH WELLPOINT","1385.46","77.91","","81.73","36.01","81.73","1 through 10","790.45","1385.46","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1778.28","1333.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1395.06","78.45","","35.15","35.15","162.55","1 through 10","889.14","1395.06","percent of total billed charges",""
"KIT CATHETER UROMAX 15FR 5MM 40MM NON COMPLIANT BALLOON DILATION ULTRA HYDROPLUS HIGH PRESSURE ENCORE 26 INFLATOR","SUP-ITM-10079297","CDM","C1726","HCPCS","0272","RC","","","","both","","","1116.96","837.72","WELLPOINT [1015]","HB CH WELLPOINT","870.22","77.91","","582.67","582.67","582.67","1 through 10","496.49","870.22","percent of total billed charges",""
"KIT CATHETER UROMAX 15FR 5MM 40MM NON COMPLIANT BALLOON DILATION ULTRA HYDROPLUS HIGH PRESSURE ENCORE 26 INFLATOR","SUP-ITM-10079297","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1116.96","837.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","876.26","78.45","","394.74","331.66","1115.07","1 through 10","558.48","876.26","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2115.00","1586.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1659.22","78.45","","7551.15","7551.15","7551.15","1 through 10","1057.5","1659.22","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","both","","","5488.00","4116.00","AETNA [1001]","HB CH AETNA HMO / PPO","3199.50","58.3","","2190.90","412.50","9264.59","16","2439.42","4275.7","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3183.04","58","","1903.20","1903.20","3826.66","1 through 10","2439.42","4275.7","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3430.00","62.5","","2186.25","2186.25","2186.25","32","2439.42","4275.7","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","both","","","5488.00","4116.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4006.24","73","","5556.60","5556.60","5556.60","1 through 10","2439.42","4275.7","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","both","","","5488.00","4116.00","WELLPOINT [1015]","HB CH WELLPOINT","4275.70","77.91","","1955.15","885.83","3150.40","26","2439.42","4275.7","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5488.00","4116.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3254.38","59.3","","831.03","253.22","2394.88","18","2744","4305.34","percent of total billed charges",""
"KIT ELECTRODE MIOM NEEDLE","SUP-ITM-10294690","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4305.34","78.45","","2481.69","1563.74","8149.28","1 through 10","2744","4305.34","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","AETNA [1001]","HB CH AETNA HMO / PPO","3123.75","58.3","","464.71","67.87","1012.10","221","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3123.75","58.3","","293.04","293.04","293.04","11","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2839.77","53","","983.89","983.89","983.89","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3107.67","58","","677.18","677.18","677.18","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3348.79","62.5","","46.58","46.58","46.58","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3911.38","73","","747.15","747.15","747.15","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2381.66","44.45","","1141.67","481.21","1141.67","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2381.66","44.45","","76.54","76.54","76.54","1 through 10","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","both","","","5358.06","4018.54","WELLPOINT [1015]","HB CH WELLPOINT","4174.46","77.91","","273.64","94.28","1367.51","138","2381.66","4174.46","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5358.06","4018.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","3177.33","59.3","","720.78","230.14","2010.94","427","2679.03","4203.4","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5358.06","4018.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3177.33","59.3","","344.45","344.45","344.45","1 through 10","2679.03","4203.4","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5358.06","4018.54","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4203.40","78.45","","1120.13","1120.13","1120.13","1 through 10","2679.03","4203.4","percent of total billed charges",""
"KIT FOOT AND ANKLE SCP 3CC SIDE-DELIVERY","SUP-ITM-10212520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5358.06","4018.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4203.40","78.45","","456.17","105.33","1284.66","242","2679.03","4203.4","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","605.00","453.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","303.11","50.1","","307.21","307.21","307.21","1 through 10","257.87","474.62","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","605.00","453.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","358.77","59.3","","344.57","344.57","344.57","1 through 10","257.87","474.62","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","AETNA [1001]","HB CH AETNA HMO / PPO","8408.70","58.3","","464.71","67.87","1012.10","221","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8408.70","58.3","","293.04","293.04","293.04","11","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7644.27","53","","983.89","983.89","983.89","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8365.43","58","","677.18","677.18","677.18","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9014.48","62.5","","46.58","46.58","46.58","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10528.91","73","","747.15","747.15","747.15","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6411.09","44.45","","1141.67","481.21","1141.67","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6411.09","44.45","","76.54","76.54","76.54","1 through 10","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","WELLPOINT [1015]","HB CH WELLPOINT","11237.08","77.91","","273.64","94.28","1367.51","138","6411.09","11237.08","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","8552.93","59.3","","720.78","230.14","2010.94","427","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","8552.93","59.3","","344.45","344.45","344.45","1 through 10","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","11314.97","78.45","","1120.13","1120.13","1120.13","1 through 10","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11314.97","78.45","","456.17","105.33","1284.66","242","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","AETNA [1001]","HB CH AETNA HMO / PPO","7551.86","58.3","","464.71","67.87","1012.10","221","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7551.86","58.3","","293.04","293.04","293.04","11","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6865.32","53","","983.89","983.89","983.89","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7513.00","58","","677.18","677.18","677.18","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8095.90","62.5","","46.58","46.58","46.58","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9456.01","73","","747.15","747.15","747.15","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5757.80","44.45","","1141.67","481.21","1141.67","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5757.80","44.45","","76.54","76.54","76.54","1 through 10","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","WELLPOINT [1015]","HB CH WELLPOINT","10092.03","77.91","","273.64","94.28","1367.51","138","5757.8","10092.03","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","7681.39","59.3","","720.78","230.14","2010.94","427","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7681.39","59.3","","344.45","344.45","344.45","1 through 10","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","10161.97","78.45","","1120.13","1120.13","1120.13","1 through 10","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10161.97","78.45","","456.17","105.33","1284.66","242","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","AETNA [1001]","HB CH AETNA HMO / PPO","5516.25","58.3","","464.71","67.87","1012.10","221","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5516.25","58.3","","293.04","293.04","293.04","11","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5014.78","53","","983.89","983.89","983.89","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5487.87","58","","677.18","677.18","677.18","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5913.65","62.5","","46.58","46.58","46.58","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6907.14","73","","747.15","747.15","747.15","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4205.79","44.45","","1141.67","481.21","1141.67","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4205.79","44.45","","76.54","76.54","76.54","1 through 10","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","WELLPOINT [1015]","HB CH WELLPOINT","7371.72","77.91","","273.64","94.28","1367.51","138","4205.79","7371.72","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","5610.87","59.3","","720.78","230.14","2010.94","427","4730.92","7422.81","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5610.87","59.3","","344.45","344.45","344.45","1 through 10","4730.92","7422.81","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7422.81","78.45","","1120.13","1120.13","1120.13","1 through 10","4730.92","7422.81","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7422.81","78.45","","456.17","105.33","1284.66","242","4730.92","7422.81","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","AETNA [1001]","HB CH AETNA HMO / PPO","964.22","58.3","","1530.90","1160.93","1884.08","89","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","876.57","53","","5253.92","5253.92","5253.92","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","959.26","58","","12181.47","12181.47","12181.47","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1033.69","62.5","","1350.68","1350.68","1350.68","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.16","44.45","","1910.74","891.94","1910.74","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","WELLPOINT [1015]","HB CH WELLPOINT","1288.55","77.91","","1829.79","1561.50","2617.12","88","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","980.76","59.3","","1359.46","1201.30","1689.00","61","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","980.76","59.3","","1718.92","1718.92","1718.92","1 through 10","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X10X10MM SPEED COMPRESSION","SUP-ITM-10211726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1297.48","78.45","","1910.74","1019.06","2344.84","74","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","AETNA [1001]","HB CH AETNA HMO / PPO","964.22","58.3","","464.71","67.87","1012.10","221","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","964.22","58.3","","293.04","293.04","293.04","11","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","876.57","53","","983.89","983.89","983.89","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","959.26","58","","677.18","677.18","677.18","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1033.69","62.5","","46.58","46.58","46.58","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1207.35","73","","747.15","747.15","747.15","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.16","44.45","","1141.67","481.21","1141.67","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.16","44.45","","76.54","76.54","76.54","1 through 10","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","WELLPOINT [1015]","HB CH WELLPOINT","1288.55","77.91","","273.64","94.28","1367.51","138","735.16","1288.55","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","980.76","59.3","","720.78","230.14","2010.94","427","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","980.76","59.3","","344.45","344.45","344.45","1 through 10","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1297.48","78.45","","1120.13","1120.13","1120.13","1 through 10","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 11X8X8MM SPEED COMPRESSION","SUP-ITM-10212943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1297.48","78.45","","456.17","105.33","1284.66","242","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","AETNA [1001]","HB CH AETNA HMO / PPO","1335.03","58.3","","1530.90","1160.93","1884.08","89","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1213.66","53","","5253.92","5253.92","5253.92","1 through 10","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1328.16","58","","12181.47","12181.47","12181.47","1 through 10","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1431.21","62.5","","1350.68","1350.68","1350.68","1 through 10","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1017.87","44.45","","1910.74","891.94","1910.74","1 through 10","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","WELLPOINT [1015]","HB CH WELLPOINT","1784.08","77.91","","1829.79","1561.50","2617.12","88","1017.87","1784.08","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.93","1717.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1357.93","59.3","","1359.46","1201.30","1689.00","61","1144.97","1796.45","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.93","1717.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1357.93","59.3","","1718.92","1718.92","1718.92","1 through 10","1144.97","1796.45","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.93","1717.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1796.45","78.45","","1910.74","1019.06","2344.84","74","1144.97","1796.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","AETNA [1001]","HB CH AETNA HMO / PPO","1719.42","58.3","","464.71","67.87","1012.10","221","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1719.42","58.3","","293.04","293.04","293.04","11","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1563.11","53","","983.89","983.89","983.89","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1710.58","58","","677.18","677.18","677.18","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1843.29","62.5","","46.58","46.58","46.58","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2152.97","73","","747.15","747.15","747.15","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1310.95","44.45","","1141.67","481.21","1141.67","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1310.95","44.45","","76.54","76.54","76.54","1 through 10","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","WELLPOINT [1015]","HB CH WELLPOINT","2297.78","77.91","","273.64","94.28","1367.51","138","1310.95","2297.78","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","1748.92","59.3","","720.78","230.14","2010.94","427","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1748.92","59.3","","344.45","344.45","344.45","1 through 10","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2313.70","78.45","","1120.13","1120.13","1120.13","1 through 10","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2313.70","78.45","","456.17","105.33","1284.66","242","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","AETNA [1001]","HB CH AETNA HMO / PPO","1881.21","58.3","","1530.90","1160.93","1884.08","89","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1710.19","53","","5253.92","5253.92","5253.92","1 through 10","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1871.53","58","","12181.47","12181.47","12181.47","1 through 10","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2016.73","62.5","","1350.68","1350.68","1350.68","1 through 10","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.30","44.45","","1910.74","891.94","1910.74","1 through 10","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","WELLPOINT [1015]","HB CH WELLPOINT","2513.98","77.91","","1829.79","1561.50","2617.12","88","1434.3","2513.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.77","2420.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","1913.47","59.3","","1359.46","1201.30","1689.00","61","1613.39","2531.4","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.77","2420.08","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1913.47","59.3","","1718.92","1718.92","1718.92","1 through 10","1613.39","2531.4","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.77","2420.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2531.40","78.45","","1910.74","1019.06","2344.84","74","1613.39","2531.4","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","AETNA [1001]","HB CH AETNA HMO / PPO","1666.36","58.3","","464.71","67.87","1012.10","221","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1666.36","58.3","","293.04","293.04","293.04","11","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1514.87","53","","983.89","983.89","983.89","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1657.79","58","","677.18","677.18","677.18","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1786.41","62.5","","46.58","46.58","46.58","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2086.52","73","","747.15","747.15","747.15","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1270.49","44.45","","1141.67","481.21","1141.67","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1270.49","44.45","","76.54","76.54","76.54","1 through 10","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","WELLPOINT [1015]","HB CH WELLPOINT","2226.86","77.91","","273.64","94.28","1367.51","138","1270.49","2226.86","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","1694.94","59.3","","720.78","230.14","2010.94","427","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1694.94","59.3","","344.45","344.45","344.45","1 through 10","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2242.30","78.45","","1120.13","1120.13","1120.13","1 through 10","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2242.30","78.45","","456.17","105.33","1284.66","242","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","AETNA [1001]","HB CH AETNA HMO / PPO","1379.96","58.3","","464.71","67.87","1012.10","221","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1379.96","58.3","","293.04","293.04","293.04","11","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1254.51","53","","983.89","983.89","983.89","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1372.86","58","","677.18","677.18","677.18","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1479.38","62.5","","46.58","46.58","46.58","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1727.91","73","","747.15","747.15","747.15","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.13","44.45","","1141.67","481.21","1141.67","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.13","44.45","","76.54","76.54","76.54","1 through 10","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","WELLPOINT [1015]","HB CH WELLPOINT","1844.13","77.91","","273.64","94.28","1367.51","138","1052.13","1844.13","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1403.63","59.3","","720.78","230.14","2010.94","427","1183.5","1856.91","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1403.63","59.3","","344.45","344.45","344.45","1 through 10","1183.5","1856.91","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1856.91","78.45","","1120.13","1120.13","1120.13","1 through 10","1183.5","1856.91","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1856.91","78.45","","456.17","105.33","1284.66","242","1183.5","1856.91","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","AETNA [1001]","HB CH AETNA HMO / PPO","676.86","58.3","","48.90","46.54","48.90","1 through 10","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","615.33","53","","91.65","91.65","91.65","1 through 10","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","673.38","58","","51.23","51.23","51.23","1 through 10","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","725.63","62.5","","65.12","36.89","65.12","1 through 10","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","847.53","73","","46.29","46.29","46.29","1 through 10","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","both","","","1161.00","870.75","WELLPOINT [1015]","HB CH WELLPOINT","904.54","77.91","","64.65","45.40","120.92","18","516.06","904.54","percent of total billed charges",""
"KIT INTRODUCER 10FR 15CM VASCULAR PTFE COATED PEEL APART PERCUTANEOUS","SUP-ITM-10027144","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1161.00","870.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","910.80","78.45","","276.77","63.10","312.43","11","580.5","910.8","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","48.90","46.54","48.90","1 through 10","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","91.65","91.65","91.65","1 through 10","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","487.20","58","","51.23","51.23","51.23","1 through 10","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","525.00","62.5","","65.12","36.89","65.12","1 through 10","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","46.29","46.29","46.29","1 through 10","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","64.65","45.40","120.92","18","373.38","654.44","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","276.77","63.10","312.43","11","420","658.98","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","AETNA [1001]","HB CH AETNA HMO / PPO","404.21","58.3","","48.90","46.54","48.90","1 through 10","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","367.46","53","","91.65","91.65","91.65","1 through 10","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","402.13","58","","51.23","51.23","51.23","1 through 10","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","433.33","62.5","","65.12","36.89","65.12","1 through 10","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","506.13","73","","46.29","46.29","46.29","1 through 10","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","693.33","520.00","WELLPOINT [1015]","HB CH WELLPOINT","540.17","77.91","","64.65","45.40","120.92","18","308.19","540.17","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","693.33","520.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","543.92","78.45","","276.77","63.10","312.43","11","346.67","543.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","AETNA [1001]","HB CH AETNA HMO / PPO","1756.00","58.3","","48.90","46.54","48.90","1 through 10","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1596.36","53","","91.65","91.65","91.65","1 through 10","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1746.96","58","","51.23","51.23","51.23","1 through 10","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1882.50","62.5","","65.12","36.89","65.12","1 through 10","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2198.76","73","","46.29","46.29","46.29","1 through 10","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","3012.00","2259.00","WELLPOINT [1015]","HB CH WELLPOINT","2346.65","77.91","","64.65","45.40","120.92","18","1338.83","2346.65","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3012.00","2259.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2362.91","78.45","","276.77","63.10","312.43","11","1506","2362.91","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","AETNA [1001]","HB CH AETNA HMO / PPO","1839.95","58.3","","464.71","67.87","1012.10","221","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1839.95","58.3","","293.04","293.04","293.04","11","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1672.68","53","","983.89","983.89","983.89","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1830.48","58","","677.18","677.18","677.18","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1972.50","62.5","","46.58","46.58","46.58","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2303.88","73","","747.15","747.15","747.15","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1402.84","44.45","","1141.67","481.21","1141.67","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1402.84","44.45","","76.54","76.54","76.54","1 through 10","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","both","","","3156.00","2367.00","WELLPOINT [1015]","HB CH WELLPOINT","2458.84","77.91","","273.64","94.28","1367.51","138","1402.84","2458.84","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3156.00","2367.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1871.51","59.3","","720.78","230.14","2010.94","427","1578","2475.88","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3156.00","2367.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1871.51","59.3","","344.45","344.45","344.45","1 through 10","1578","2475.88","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3156.00","2367.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2475.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1578","2475.88","percent of total billed charges",""
"KIT K-WIRE AND DILATOR NVM5 XLIF","SUP-ITM-10294706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3156.00","2367.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2475.88","78.45","","456.17","105.33","1284.66","242","1578","2475.88","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","AETNA [1001]","HB CH AETNA HMO / PPO","3971.40","58.3","","1530.90","1160.93","1884.08","89","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3610.36","53","","5253.92","5253.92","5253.92","1 through 10","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3950.96","58","","12181.47","12181.47","12181.47","1 through 10","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4257.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3027.93","44.45","","1910.74","891.94","1910.74","1 through 10","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","WELLPOINT [1015]","HB CH WELLPOINT","5307.23","77.91","","1829.79","1561.50","2617.12","88","3027.93","5307.23","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6812.00","5109.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4039.52","59.3","","1359.46","1201.30","1689.00","61","3406","5344.01","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6812.00","5109.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4039.52","59.3","","1718.92","1718.92","1718.92","1 through 10","3406","5344.01","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6812.00","5109.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5344.01","78.45","","1910.74","1019.06","2344.84","74","3406","5344.01","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","AETNA [1001]","HB CH AETNA HMO / PPO","2009.60","58.3","","464.71","67.87","1012.10","221","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2009.60","58.3","","293.04","293.04","293.04","11","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1826.91","53","","983.89","983.89","983.89","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1999.26","58","","677.18","677.18","677.18","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2154.38","62.5","","46.58","46.58","46.58","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2516.31","73","","747.15","747.15","747.15","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1532.19","44.45","","1141.67","481.21","1141.67","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1532.19","44.45","","76.54","76.54","76.54","1 through 10","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","WELLPOINT [1015]","HB CH WELLPOINT","2685.56","77.91","","273.64","94.28","1367.51","138","1532.19","2685.56","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2044.07","59.3","","720.78","230.14","2010.94","427","1723.5","2704.17","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2044.07","59.3","","344.45","344.45","344.45","1 through 10","1723.5","2704.17","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2704.17","78.45","","1120.13","1120.13","1120.13","1 through 10","1723.5","2704.17","percent of total billed charges",""
"KIT LABORATORY PLATE SCREW ACU SINCH","SUP-ITM-10135420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2704.17","78.45","","456.17","105.33","1284.66","242","1723.5","2704.17","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","AETNA [1001]","HB CH AETNA HMO / PPO","2438.11","58.3","","6038.55","6038.55","6038.55","1 through 10","2216.46","3258.2","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2479.93","59.3","","3120.45","3120.45","3120.45","1 through 10","1858.9","3280.78","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3280.78","78.45","","5458.48","2426.07","8187.72","1 through 10","1858.9","3280.78","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","7100.00","5325.00","AETNA [1001]","HB CH AETNA HMO / PPO","4139.30","58.3","","6038.55","6038.55","6038.55","1 through 10","3763","5531.61","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7100.00","5325.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4210.30","59.3","","3120.45","3120.45","3120.45","1 through 10","3155.95","5569.95","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7100.00","5325.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5569.95","78.45","","5458.48","2426.07","8187.72","1 through 10","3155.95","5569.95","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","7100.00","5325.00","AETNA [1001]","HB CH AETNA HMO / PPO","4139.30","58.3","","6038.55","6038.55","6038.55","1 through 10","3763","5531.61","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7100.00","5325.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4210.30","59.3","","3120.45","3120.45","3120.45","1 through 10","3155.95","5569.95","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7100.00","5325.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5569.95","78.45","","5458.48","2426.07","8187.72","1 through 10","3155.95","5569.95","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","AETNA [1001]","HB CH AETNA HMO / PPO","297.33","58.3","","464.71","67.87","1012.10","221","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","297.33","58.3","","293.04","293.04","293.04","11","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","270.30","53","","983.89","983.89","983.89","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","295.80","58","","677.18","677.18","677.18","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","318.75","62.5","","46.58","46.58","46.58","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","747.15","747.15","747.15","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","1141.67","481.21","1141.67","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","76.54","76.54","76.54","1 through 10","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","WELLPOINT [1015]","HB CH WELLPOINT","397.34","77.91","","273.64","94.28","1367.51","138","226.7","397.34","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.43","59.3","","720.78","230.14","2010.94","427","255","400.1","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","302.43","59.3","","344.45","344.45","344.45","1 through 10","255","400.1","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","1120.13","1120.13","1120.13","1 through 10","255","400.1","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","456.17","105.33","1284.66","242","255","400.1","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","AETNA [1001]","HB CH AETNA HMO / PPO","4195.61","58.3","","464.71","67.87","1012.10","221","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4195.61","58.3","","293.04","293.04","293.04","11","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3814.19","53","","983.89","983.89","983.89","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4174.02","58","","677.18","677.18","677.18","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4497.86","62.5","","46.58","46.58","46.58","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","747.15","747.15","747.15","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","1141.67","481.21","1141.67","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","76.54","76.54","76.54","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","WELLPOINT [1015]","HB CH WELLPOINT","5606.86","77.91","","273.64","94.28","1367.51","138","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4267.57","59.3","","720.78","230.14","2010.94","427","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4267.57","59.3","","344.45","344.45","344.45","1 through 10","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","1120.13","1120.13","1120.13","1 through 10","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X320MM LONG 125DEG BONE GAMMA 3 TITANIUM RIGHT","SUP-ITM-10086358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","456.17","105.33","1284.66","242","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","AETNA [1001]","HB CH AETNA HMO / PPO","4195.61","58.3","","464.71","67.87","1012.10","221","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4195.61","58.3","","293.04","293.04","293.04","11","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3814.19","53","","983.89","983.89","983.89","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4174.02","58","","677.18","677.18","677.18","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4497.86","62.5","","46.58","46.58","46.58","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","747.15","747.15","747.15","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","1141.67","481.21","1141.67","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","76.54","76.54","76.54","1 through 10","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","WELLPOINT [1015]","HB CH WELLPOINT","5606.86","77.91","","273.64","94.28","1367.51","138","3198.88","5606.86","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4267.57","59.3","","720.78","230.14","2010.94","427","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4267.57","59.3","","344.45","344.45","344.45","1 through 10","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","1120.13","1120.13","1120.13","1 through 10","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","456.17","105.33","1284.66","242","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","AETNA [1001]","HB CH AETNA HMO / PPO","2536.59","58.3","","464.71","67.87","1012.10","221","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2536.59","58.3","","293.04","293.04","293.04","11","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2305.99","53","","983.89","983.89","983.89","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2523.53","58","","677.18","677.18","677.18","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2719.33","62.5","","46.58","46.58","46.58","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3176.17","73","","747.15","747.15","747.15","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.98","44.45","","1141.67","481.21","1141.67","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.98","44.45","","76.54","76.54","76.54","1 through 10","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","WELLPOINT [1015]","HB CH WELLPOINT","3389.80","77.91","","273.64","94.28","1367.51","138","1933.98","3389.8","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2580.10","59.3","","720.78","230.14","2010.94","427","2175.46","3413.3","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2580.10","59.3","","344.45","344.45","344.45","1 through 10","2175.46","3413.3","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3413.30","78.45","","1120.13","1120.13","1120.13","1 through 10","2175.46","3413.3","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3413.30","78.45","","456.17","105.33","1284.66","242","2175.46","3413.3","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","both","","","384.00","288.00","AETNA [1001]","HB CH AETNA HMO / PPO","223.87","58.3","","34.87","34.02","34.87","1 through 10","170.69","299.17","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","both","","","384.00","288.00","WELLPOINT [1015]","HB CH WELLPOINT","299.17","77.91","","81.73","36.01","81.73","1 through 10","170.69","299.17","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","384.00","288.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","301.25","78.45","","35.15","35.15","162.55","1 through 10","192","301.25","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"KIT PNEUMOTHORAX X RX 8FR 6.44IN 16CM 18GA SHARPS SAFETY FEATURE CS/5EA","SUP-ITM-10009699","CDM","C1729","HCPCS","0272","RC","","","","both","","","295.37","221.53","AETNA [1001]","HB CH AETNA HMO / PPO","172.20","58.3","","34.87","34.02","34.87","1 through 10","131.29","230.12","percent of total billed charges",""
"KIT PNEUMOTHORAX X RX 8FR 6.44IN 16CM 18GA SHARPS SAFETY FEATURE CS/5EA","SUP-ITM-10009699","CDM","C1729","HCPCS","0272","RC","","","","both","","","295.37","221.53","WELLPOINT [1015]","HB CH WELLPOINT","230.12","77.91","","81.73","36.01","81.73","1 through 10","131.29","230.12","percent of total billed charges",""
"KIT PNEUMOTHORAX X RX 8FR 6.44IN 16CM 18GA SHARPS SAFETY FEATURE CS/5EA","SUP-ITM-10009699","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","295.37","221.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.72","78.45","","35.15","35.15","162.55","1 through 10","147.69","231.72","percent of total billed charges",""
"KIT PORT 6.0FR INFUSION VASCULAR MRI POWER ISP PLASTIC ATTACHABLE POLYURETHANE CATHETER ATTACHED SUTURE PLUG","SUP-ITM-10030773","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","AETNA [1001]","HB CH AETNA HMO / PPO","608.65","58.3","","270.46","270.46","331.70","1 through 10","553.32","813.38","percent of total billed charges",""
"KIT PORT 6.0FR INFUSION VASCULAR MRI POWER ISP PLASTIC ATTACHABLE POLYURETHANE CATHETER ATTACHED SUTURE PLUG","SUP-ITM-10030773","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","762.12","73","","329.93","269.03","329.93","1 through 10","553.32","813.38","percent of total billed charges",""
"KIT PORT 6.0FR INFUSION VASCULAR MRI POWER ISP PLASTIC ATTACHABLE POLYURETHANE CATHETER ATTACHED SUTURE PLUG","SUP-ITM-10030773","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","WELLPOINT [1015]","HB CH WELLPOINT","813.38","77.91","","375.69","375.69","375.69","1 through 10","553.32","813.38","percent of total billed charges",""
"KIT PORT 6.0FR INFUSION VASCULAR MRI POWER ISP PLASTIC ATTACHABLE POLYURETHANE CATHETER ATTACHED SUTURE PLUG","SUP-ITM-10030773","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1044.00","783.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","619.09","59.3","","279.52","279.52","279.52","1 through 10","464.06","819.02","percent of total billed charges",""
"KIT PORT 6.0FR INFUSION VASCULAR MRI POWER ISP PLASTIC ATTACHABLE POLYURETHANE CATHETER ATTACHED SUTURE PLUG","SUP-ITM-10030773","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1044.00","783.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","819.02","78.45","","366.72","217.32","449.75","1 through 10","464.06","819.02","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","1530.90","1160.93","1884.08","89","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","5253.92","5253.92","5253.92","1 through 10","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1557.30","58","","12181.47","12181.47","12181.47","1 through 10","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1678.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","1910.74","891.94","1910.74","1 through 10","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","1829.79","1561.50","2617.12","88","1193.48","2091.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","1359.46","1201.30","1689.00","61","1342.5","2106.38","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1592.21","59.3","","1718.92","1718.92","1718.92","1 through 10","1342.5","2106.38","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","1910.74","1019.06","2344.84","74","1342.5","2106.38","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","AETNA [1001]","HB CH AETNA HMO / PPO","918.23","58.3","","464.71","67.87","1012.10","221","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","918.23","58.3","","293.04","293.04","293.04","11","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","834.75","53","","983.89","983.89","983.89","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","913.50","58","","677.18","677.18","677.18","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","984.38","62.5","","46.58","46.58","46.58","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","747.15","747.15","747.15","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","1141.67","481.21","1141.67","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","76.54","76.54","76.54","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB CH WELLPOINT","1227.08","77.91","","273.64","94.28","1367.51","138","700.09","1227.08","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","933.98","59.3","","720.78","230.14","2010.94","427","787.5","1235.59","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","933.98","59.3","","344.45","344.45","344.45","1 through 10","787.5","1235.59","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","1120.13","1120.13","1120.13","1 through 10","787.5","1235.59","percent of total billed charges",""
"KIT REPAIR 1.1MM SYNDESMOSIS TIGHTROPE MINI","SUP-ITM-10046550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","456.17","105.33","1284.66","242","787.5","1235.59","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","AETNA [1001]","HB CH AETNA HMO / PPO","1705.28","58.3","","464.71","67.87","1012.10","221","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1705.28","58.3","","293.04","293.04","293.04","11","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1550.25","53","","983.89","983.89","983.89","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1696.50","58","","677.18","677.18","677.18","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1828.13","62.5","","46.58","46.58","46.58","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","747.15","747.15","747.15","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.16","44.45","","1141.67","481.21","1141.67","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.16","44.45","","76.54","76.54","76.54","1 through 10","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","WELLPOINT [1015]","HB CH WELLPOINT","2278.87","77.91","","273.64","94.28","1367.51","138","1300.16","2278.87","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1734.53","59.3","","720.78","230.14","2010.94","427","1462.5","2294.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1734.53","59.3","","344.45","344.45","344.45","1 through 10","1462.5","2294.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1462.5","2294.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","456.17","105.33","1284.66","242","1462.5","2294.66","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","AETNA [1001]","HB CH AETNA HMO / PPO","1168.33","58.3","","464.71","67.87","1012.10","221","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1168.33","58.3","","293.04","293.04","293.04","11","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1062.12","53","","983.89","983.89","983.89","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1162.32","58","","677.18","677.18","677.18","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1252.50","62.5","","46.58","46.58","46.58","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1462.92","73","","747.15","747.15","747.15","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","890.78","44.45","","1141.67","481.21","1141.67","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","890.78","44.45","","76.54","76.54","76.54","1 through 10","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","both","","","2004.00","1503.00","WELLPOINT [1015]","HB CH WELLPOINT","1561.32","77.91","","273.64","94.28","1367.51","138","890.78","1561.32","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2004.00","1503.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1188.37","59.3","","720.78","230.14","2010.94","427","1002","1572.14","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2004.00","1503.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1188.37","59.3","","344.45","344.45","344.45","1 through 10","1002","1572.14","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2004.00","1503.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1572.14","78.45","","1120.13","1120.13","1120.13","1 through 10","1002","1572.14","percent of total billed charges",""
"KIT REPAIR TFCC FAST FIX FIBROCARTILAGE TRIANGULAR","SUP-ITM-10133317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2004.00","1503.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1572.14","78.45","","456.17","105.33","1284.66","242","1002","1572.14","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","AETNA [1001]","HB CH AETNA HMO / PPO","2106.09","58.3","","464.71","67.87","1012.10","221","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2106.09","58.3","","293.04","293.04","293.04","11","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1914.63","53","","983.89","983.89","983.89","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2095.25","58","","677.18","677.18","677.18","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2257.81","62.5","","46.58","46.58","46.58","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2637.13","73","","747.15","747.15","747.15","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.76","44.45","","1141.67","481.21","1141.67","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.76","44.45","","76.54","76.54","76.54","1 through 10","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.50","2709.37","WELLPOINT [1015]","HB CH WELLPOINT","2814.50","77.91","","273.64","94.28","1367.51","138","1605.76","2814.5","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.50","2709.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2142.21","59.3","","720.78","230.14","2010.94","427","1806.25","2834.01","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.50","2709.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2142.21","59.3","","344.45","344.45","344.45","1 through 10","1806.25","2834.01","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.50","2709.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2834.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1806.25","2834.01","percent of total billed charges",""
"KIT SCREW 110MM 105 11X7 BONE INTEGRATED INTERLOCKING TRIGEN INTERTAN TITANIUM LAG COMPRESSION","SUP-ITM-10063806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.50","2709.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2834.01","78.45","","456.17","105.33","1284.66","242","1806.25","2834.01","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","AETNA [1001]","HB CH AETNA HMO / PPO","2055.08","58.3","","464.71","67.87","1012.10","221","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2055.08","58.3","","293.04","293.04","293.04","11","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1868.25","53","","983.89","983.89","983.89","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2044.50","58","","677.18","677.18","677.18","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2203.13","62.5","","46.58","46.58","46.58","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2573.25","73","","747.15","747.15","747.15","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","1141.67","481.21","1141.67","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","76.54","76.54","76.54","1 through 10","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","WELLPOINT [1015]","HB CH WELLPOINT","2746.33","77.91","","273.64","94.28","1367.51","138","1566.86","2746.33","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2090.33","59.3","","720.78","230.14","2010.94","427","1762.5","2765.36","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2090.33","59.3","","344.45","344.45","344.45","1 through 10","1762.5","2765.36","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1762.5","2765.36","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","456.17","105.33","1284.66","242","1762.5","2765.36","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","AETNA [1001]","HB CH AETNA HMO / PPO","918.23","58.3","","464.71","67.87","1012.10","221","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","918.23","58.3","","293.04","293.04","293.04","11","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","834.75","53","","983.89","983.89","983.89","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","913.50","58","","677.18","677.18","677.18","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","984.38","62.5","","46.58","46.58","46.58","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","747.15","747.15","747.15","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","1141.67","481.21","1141.67","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","76.54","76.54","76.54","1 through 10","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB CH WELLPOINT","1227.08","77.91","","273.64","94.28","1367.51","138","700.09","1227.08","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","933.98","59.3","","720.78","230.14","2010.94","427","787.5","1235.59","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","933.98","59.3","","344.45","344.45","344.45","1 through 10","787.5","1235.59","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","1120.13","1120.13","1120.13","1 through 10","787.5","1235.59","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE TITANIUM CANNULATED SYNDESMOSIS REPAIR","SUP-ITM-10036209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","456.17","105.33","1284.66","242","787.5","1235.59","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","2964.00","2223.00","AETNA [1001]","HB CH AETNA HMO / PPO","1728.01","58.3","","1952.48","1215.31","1952.48","1 through 10","1317.5","2309.25","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","2964.00","2223.00","WELLPOINT [1015]","HB CH WELLPOINT","2309.25","77.91","","2735.63","2146.75","4736.42","1 through 10","1317.5","2309.25","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2964.00","2223.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1757.65","59.3","","1597.25","1552.67","1756.87","1 through 10","1482","2325.26","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2964.00","2223.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2325.26","78.45","","2647.39","1568.87","3176.87","1 through 10","1482","2325.26","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","509.28","381.96","AETNA [1001]","HB CH AETNA HMO / PPO","296.91","58.3","","188.13","151.57","188.13","1 through 10","226.37","396.78","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","509.28","381.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","269.92","53","","175.85","175.85","175.85","1 through 10","226.37","396.78","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","509.28","381.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.37","44.45","","255.09","255.09","255.09","1 through 10","226.37","396.78","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","509.28","381.96","WELLPOINT [1015]","HB CH WELLPOINT","396.78","77.91","","261.33","130.66","261.33","1 through 10","226.37","396.78","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","509.28","381.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.00","59.3","","194.43","189.79","327.42","11","254.64","399.53","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","509.28","381.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","399.53","78.45","","255.09","151.17","255.09","1 through 10","254.64","399.53","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","AETNA [1001]","HB CH AETNA HMO / PPO","2666.64","58.3","","2190.90","412.50","9264.59","16","2033.14","3563.6","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2652.92","58","","1903.20","1903.20","3826.66","1 through 10","2033.14","3563.6","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2858.75","62.5","","2186.25","2186.25","2186.25","32","2033.14","3563.6","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3339.02","73","","5556.60","5556.60","5556.60","1 through 10","2033.14","3563.6","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","WELLPOINT [1015]","HB CH WELLPOINT","3563.60","77.91","","1955.15","885.83","3150.40","26","2033.14","3563.6","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4574.00","3430.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2712.38","59.3","","831.03","253.22","2394.88","18","2287","3588.3","percent of total billed charges",""
"KIT TRAY 10/3 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10018114","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4574.00","3430.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3588.30","78.45","","2481.69","1563.74","8149.28","1 through 10","2287","3588.3","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","4646.00","3484.50","AETNA [1001]","HB CH AETNA HMO / PPO","2708.62","58.3","","2190.90","412.50","9264.59","16","2065.15","3619.7","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","4646.00","3484.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2694.68","58","","1903.20","1903.20","3826.66","1 through 10","2065.15","3619.7","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","4646.00","3484.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2903.75","62.5","","2186.25","2186.25","2186.25","32","2065.15","3619.7","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","4646.00","3484.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3391.58","73","","5556.60","5556.60","5556.60","1 through 10","2065.15","3619.7","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","4646.00","3484.50","WELLPOINT [1015]","HB CH WELLPOINT","3619.70","77.91","","1955.15","885.83","3150.40","26","2065.15","3619.7","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4646.00","3484.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2755.08","59.3","","831.03","253.22","2394.88","18","2323","3644.79","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4646.00","3484.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3644.79","78.45","","2481.69","1563.74","8149.28","1 through 10","2323","3644.79","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","both","","","5978.00","4483.50","AETNA [1001]","HB CH AETNA HMO / PPO","3485.17","58.3","","2190.90","412.50","9264.59","16","2657.22","4657.46","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","both","","","5978.00","4483.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3467.24","58","","1903.20","1903.20","3826.66","1 through 10","2657.22","4657.46","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","both","","","5978.00","4483.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3736.25","62.5","","2186.25","2186.25","2186.25","32","2657.22","4657.46","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","both","","","5978.00","4483.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4363.94","73","","5556.60","5556.60","5556.60","1 through 10","2657.22","4657.46","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","both","","","5978.00","4483.50","WELLPOINT [1015]","HB CH WELLPOINT","4657.46","77.91","","1955.15","885.83","3150.40","26","2657.22","4657.46","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5978.00","4483.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3544.95","59.3","","831.03","253.22","2394.88","18","2989","4689.74","percent of total billed charges",""
"KIT TRAY 15X3MM SURGICAL KYPHOPAK BONE FIRST FRACTURE EXPRESS OSTEO INTRODUCER","SUP-ITM-10016006","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5978.00","4483.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4689.74","78.45","","2481.69","1563.74","8149.28","1 through 10","2989","4689.74","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","AETNA [1001]","HB CH AETNA HMO / PPO","1836.45","58.3","","1786.05","1786.05","1786.05","1 through 10","747.41","2454.17","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1867.95","59.3","","1845.90","1845.90","1845.90","1 through 10","1400.18","2471.18","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2471.18","78.45","","2421.72","2421.72","2421.72","1 through 10","1400.18","2471.18","percent of total billed charges",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","186464.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","21238.2456","","Fee schedule rate ($141,976.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21238.2456","141976.54","141976.54","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","132708.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","64739.51","","Standard inlier is a Case rate ($64,739.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $73,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,189.50) for the length of stay and the standard reimbursement.","49437.44","49437.44","49437.44","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31376.75","","Standard inlier is a Case rate ($31,376.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,454.05) for the length of stay and the standard reimbursement.","31376.74","31376.74","31376.74","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","33704.89","","Standard inlier is a Case rate ($33,704.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,784.27) for the length of stay and the standard reimbursement.","32172.84","32172.84","32172.84","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","MASSHEALTH [3001]","HB NWH MEDICAID","12046.25","","Case rate ($12,977.93). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,407.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6466.85","6466.85","13011.30","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13955.10","","Fee schedule rate ($13,955.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13955.10","13955.10","13955.10","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29744.63","","Fee schedule rate ($29,744.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29744.63","29744.63","29744.63","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","57123.87","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","12046.25","","Case rate ($12,977.93). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,407.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9618.85","9618.85","9618.85","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","53134.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41307.78","","Standard inlier is a Case rate ($41,307.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,025, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,863.80) for the length of stay and the standard reimbursement.","41307.77","41307.77","41307.77","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","53134.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","21238.2456","","Fee schedule rate ($32,627.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21238.2456","32627.32","32627.32","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","53134.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","19327.05","","Fee schedule rate ($19,327.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18407.49","18407.49","18407.49","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","53134.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","39234.68","","Fee schedule rate ($39,234.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39234.68","39234.68","39234.68","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","53134.95","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","17667.83","","Case rate ($19,034.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $61,464.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26333.55","26333.55","26333.55","1 through 10","11861.93","234259.11","case rate",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","AETNA [1001]","HB CH AETNA HMO / PPO","797.54","58.3","","1530.90","1160.93","1884.08","89","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","725.04","53","","5253.92","5253.92","5253.92","1 through 10","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","793.44","58","","12181.47","12181.47","12181.47","1 through 10","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","855.00","62.5","","1350.68","1350.68","1350.68","1 through 10","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.08","44.45","","1910.74","891.94","1910.74","1 through 10","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","WELLPOINT [1015]","HB CH WELLPOINT","1065.81","77.91","","1829.79","1561.50","2617.12","88","608.08","1065.81","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","811.22","59.3","","1359.46","1201.30","1689.00","61","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","811.22","59.3","","1718.92","1718.92","1718.92","1 through 10","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 15MM SZ 4 GENESIS II ALL POLYETHYLENE STABILIZING RT","SUP-ITM-10121284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1073.20","78.45","","1910.74","1019.06","2344.84","74","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","464.71","67.87","1012.10","221","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","293.04","293.04","293.04","11","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","983.89","983.89","983.89","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","677.18","677.18","677.18","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","46.58","46.58","46.58","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","747.15","747.15","747.15","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1141.67","481.21","1141.67","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","76.54","76.54","76.54","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","273.64","94.28","1367.51","138","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","720.78","230.14","2010.94","427","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","344.45","344.45","344.45","1 through 10","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1120.13","1120.13","1120.13","1 through 10","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","456.17","105.33","1284.66","242","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","464.71","67.87","1012.10","221","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","293.04","293.04","293.04","11","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","983.89","983.89","983.89","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1151.01","58","","677.18","677.18","677.18","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1240.31","62.5","","46.58","46.58","46.58","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","747.15","747.15","747.15","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","1141.67","481.21","1141.67","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","76.54","76.54","76.54","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","273.64","94.28","1367.51","138","882.11","1546.12","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","720.78","230.14","2010.94","427","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1176.81","59.3","","344.45","344.45","344.45","1 through 10","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","1120.13","1120.13","1120.13","1 through 10","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","456.17","105.33","1284.66","242","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1530.90","1160.93","1884.08","89","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","5253.92","5253.92","5253.92","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","12181.47","12181.47","12181.47","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1910.74","891.94","1910.74","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","1829.79","1561.50","2617.12","88","1466.85","2571.03","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1359.46","1201.30","1689.00","61","1650","2588.85","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1718.92","1718.92","1718.92","1 through 10","1650","2588.85","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1910.74","1019.06","2344.84","74","1650","2588.85","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","464.71","67.87","1012.10","221","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","293.04","293.04","293.04","11","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","983.89","983.89","983.89","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","677.18","677.18","677.18","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","46.58","46.58","46.58","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","747.15","747.15","747.15","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1141.67","481.21","1141.67","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","76.54","76.54","76.54","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","273.64","94.28","1367.51","138","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","720.78","230.14","2010.94","427","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","344.45","344.45","344.45","1 through 10","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1120.13","1120.13","1120.13","1 through 10","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","456.17","105.33","1284.66","242","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1530.90","1160.93","1884.08","89","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","5253.92","5253.92","5253.92","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","12181.47","12181.47","12181.47","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","1350.68","1350.68","1350.68","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1910.74","891.94","1910.74","1 through 10","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","1829.79","1561.50","2617.12","88","840.11","1472.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1359.46","1201.30","1689.00","61","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1718.92","1718.92","1718.92","1 through 10","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1910.74","1019.06","2344.84","74","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1530.90","1160.93","1884.08","89","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","5253.92","5253.92","5253.92","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1934.88","58","","12181.47","12181.47","12181.47","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2085.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.85","44.45","","1910.74","891.94","1910.74","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","1829.79","1561.50","2617.12","88","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1359.46","1201.30","1689.00","61","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","1910.74","1019.06","2344.84","74","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1530.90","1160.93","1884.08","89","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","5253.92","5253.92","5253.92","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1934.88","58","","12181.47","12181.47","12181.47","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2085.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.85","44.45","","1910.74","891.94","1910.74","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","1829.79","1561.50","2617.12","88","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1359.46","1201.30","1689.00","61","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","1910.74","1019.06","2344.84","74","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1530.90","1160.93","1884.08","89","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","5253.92","5253.92","5253.92","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1934.88","58","","12181.47","12181.47","12181.47","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2085.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.85","44.45","","1910.74","891.94","1910.74","1 through 10","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","1829.79","1561.50","2617.12","88","1482.85","2599.08","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1359.46","1201.30","1689.00","61","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","1910.74","1019.06","2344.84","74","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1530.90","1160.93","1884.08","89","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","5253.92","5253.92","5253.92","1 through 10","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","12181.47","12181.47","12181.47","1 through 10","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1910.74","891.94","1910.74","1 through 10","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","1829.79","1561.50","2617.12","88","1066.8","1869.84","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1359.46","1201.30","1689.00","61","1200","1882.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1718.92","1718.92","1718.92","1 through 10","1200","1882.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1910.74","1019.06","2344.84","74","1200","1882.8","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1530.90","1160.93","1884.08","89","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","5253.92","5253.92","5253.92","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","869.65","58","","12181.47","12181.47","12181.47","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.13","62.5","","1350.68","1350.68","1350.68","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.48","44.45","","1910.74","891.94","1910.74","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","1829.79","1561.50","2617.12","88","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1359.46","1201.30","1689.00","61","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.14","59.3","","1718.92","1718.92","1718.92","1 through 10","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","1910.74","1019.06","2344.84","74","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","AETNA [1001]","HB CH AETNA HMO / PPO","2031.11","58.3","","1530.90","1160.93","1884.08","89","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.47","53","","5253.92","5253.92","5253.92","1 through 10","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2020.66","58","","12181.47","12181.47","12181.47","1 through 10","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2177.44","62.5","","1350.68","1350.68","1350.68","1 through 10","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.59","44.45","","1910.74","891.94","1910.74","1 through 10","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","WELLPOINT [1015]","HB CH WELLPOINT","2714.31","77.91","","1829.79","1561.50","2617.12","88","1548.59","2714.31","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","2065.95","59.3","","1359.46","1201.30","1689.00","61","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2065.95","59.3","","1718.92","1718.92","1718.92","1 through 10","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.12","78.45","","1910.74","1019.06","2344.84","74","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1530.90","1160.93","1884.08","89","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","5253.92","5253.92","5253.92","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","869.65","58","","12181.47","12181.47","12181.47","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.13","62.5","","1350.68","1350.68","1350.68","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.48","44.45","","1910.74","891.94","1910.74","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","1829.79","1561.50","2617.12","88","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1359.46","1201.30","1689.00","61","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.14","59.3","","1718.92","1718.92","1718.92","1 through 10","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","1910.74","1019.06","2344.84","74","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1530.90","1160.93","1884.08","89","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","5253.92","5253.92","5253.92","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","869.65","58","","12181.47","12181.47","12181.47","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.13","62.5","","1350.68","1350.68","1350.68","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.48","44.45","","1910.74","891.94","1910.74","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","1829.79","1561.50","2617.12","88","666.48","1168.18","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1359.46","1201.30","1689.00","61","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.14","59.3","","1718.92","1718.92","1718.92","1 through 10","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING XSM SIZE 4 TIBIAL OXFORD ANATOMIC POLYETHYLENE LEFT","SUP-ITM-10029438","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","1910.74","1019.06","2344.84","74","749.7","1176.28","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","AETNA [1001]","HB CH AETNA HMO / PPO","2384.32","58.3","","1530.90","1160.93","1884.08","89","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2167.57","53","","5253.92","5253.92","5253.92","1 through 10","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2372.06","58","","12181.47","12181.47","12181.47","1 through 10","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2556.09","62.5","","1350.68","1350.68","1350.68","1 through 10","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1817.89","44.45","","1910.74","891.94","1910.74","1 through 10","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","both","","","4089.75","3067.31","WELLPOINT [1015]","HB CH WELLPOINT","3186.32","77.91","","1829.79","1561.50","2617.12","88","1817.89","3186.32","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4089.75","3067.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2425.22","59.3","","1359.46","1201.30","1689.00","61","2044.88","3208.41","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4089.75","3067.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2425.22","59.3","","1718.92","1718.92","1718.92","1 through 10","2044.88","3208.41","percent of total billed charges",""
"KNEE COMPONENT 12MM SIZE 6 TIB PLT NXGN CR TRABECULAR METAL MONOBLOCK IMPLANT 03 NC","SUP-ITM-10051968","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4089.75","3067.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3208.41","78.45","","1910.74","1019.06","2344.84","74","2044.88","3208.41","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","1530.90","1160.93","1884.08","89","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","5253.92","5253.92","5253.92","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","487.20","58","","12181.47","12181.47","12181.47","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","525.00","62.5","","1350.68","1350.68","1350.68","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","1910.74","891.94","1910.74","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","1829.79","1561.50","2617.12","88","373.38","654.44","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","1359.46","1201.30","1689.00","61","420","658.98","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","498.12","59.3","","1718.92","1718.92","1718.92","1 through 10","420","658.98","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","1910.74","1019.06","2344.84","74","420","658.98","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1530.90","1160.93","1884.08","89","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","5253.92","5253.92","5253.92","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2131.50","58","","12181.47","12181.47","12181.47","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2296.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","1910.74","891.94","1910.74","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","1829.79","1561.50","2617.12","88","1633.54","2863.19","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1359.46","1201.30","1689.00","61","1837.5","2883.04","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1837.5","2883.04","percent of total billed charges",""
"KNEE COMPONENT SZ 4 LT FEMORAL PERSONA CEMENTED CR STANDARD NITRIDE","SUP-ITM-10282861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","1910.74","1019.06","2344.84","74","1837.5","2883.04","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1530.90","1160.93","1884.08","89","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","5253.92","5253.92","5253.92","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2752.68","58","","12181.47","12181.47","12181.47","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2966.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2109.60","44.45","","1910.74","891.94","1910.74","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","1829.79","1561.50","2617.12","88","2109.6","3697.61","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1359.46","1201.30","1689.00","61","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","1910.74","1019.06","2344.84","74","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1530.90","1160.93","1884.08","89","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","5253.92","5253.92","5253.92","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2031.62","58","","12181.47","12181.47","12181.47","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2189.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","1910.74","891.94","1910.74","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","1829.79","1561.50","2617.12","88","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1359.46","1201.30","1689.00","61","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1718.92","1718.92","1718.92","1 through 10","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT SZC LEFT TIBIAL PERSONA REVERSION FIXED KEEL CEMENT","SUP-ITM-10268183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","1910.74","1019.06","2344.84","74","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1530.90","1160.93","1884.08","89","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","5253.92","5253.92","5253.92","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2031.62","58","","12181.47","12181.47","12181.47","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2189.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","1910.74","891.94","1910.74","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","1829.79","1561.50","2617.12","88","1556.99","2729.03","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1359.46","1201.30","1689.00","61","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1718.92","1718.92","1718.92","1 through 10","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","1910.74","1019.06","2344.84","74","1751.4","2747.95","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","AETNA [1001]","HB CH AETNA HMO / PPO","2125.62","58.3","","1530.90","1160.93","1884.08","89","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1932.38","53","","5253.92","5253.92","5253.92","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2114.68","58","","12181.47","12181.47","12181.47","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2278.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1620.65","44.45","","1910.74","891.94","1910.74","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","WELLPOINT [1015]","HB CH WELLPOINT","2840.60","77.91","","1829.79","1561.50","2617.12","88","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2162.08","59.3","","1359.46","1201.30","1689.00","61","1823","2860.29","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2162.08","59.3","","1718.92","1718.92","1718.92","1 through 10","1823","2860.29","percent of total billed charges",""
"KNEE CONE 18MM TIBIAL SHORT LEGION","SUP-ITM-10198691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2860.29","78.45","","1910.74","1019.06","2344.84","74","1823","2860.29","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","AETNA [1001]","HB CH AETNA HMO / PPO","2125.62","58.3","","1530.90","1160.93","1884.08","89","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1932.38","53","","5253.92","5253.92","5253.92","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2114.68","58","","12181.47","12181.47","12181.47","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2278.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1620.65","44.45","","1910.74","891.94","1910.74","1 through 10","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","3646.00","2734.50","WELLPOINT [1015]","HB CH WELLPOINT","2840.60","77.91","","1829.79","1561.50","2617.12","88","1620.65","2840.6","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2162.08","59.3","","1359.46","1201.30","1689.00","61","1823","2860.29","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2162.08","59.3","","1718.92","1718.92","1718.92","1 through 10","1823","2860.29","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3646.00","2734.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2860.29","78.45","","1910.74","1019.06","2344.84","74","1823","2860.29","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","AETNA [1001]","HB CH AETNA HMO / PPO","3539.98","58.3","","1530.90","1160.93","1884.08","89","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3218.16","53","","5253.92","5253.92","5253.92","1 through 10","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3521.76","58","","12181.47","12181.47","12181.47","1 through 10","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3795.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2699.00","44.45","","1910.74","891.94","1910.74","1 through 10","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","WELLPOINT [1015]","HB CH WELLPOINT","4730.70","77.91","","1829.79","1561.50","2617.12","88","2699","4730.7","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3600.70","59.3","","1359.46","1201.30","1689.00","61","3036","4763.48","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3600.70","59.3","","1718.92","1718.92","1718.92","1 through 10","3036","4763.48","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4763.48","78.45","","1910.74","1019.06","2344.84","74","3036","4763.48","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","AETNA [1001]","HB CH AETNA HMO / PPO","2231.90","58.3","","1530.90","1160.93","1884.08","89","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2029.00","53","","5253.92","5253.92","5253.92","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2220.41","58","","12181.47","12181.47","12181.47","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2392.69","62.5","","1350.68","1350.68","1350.68","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.68","44.45","","1910.74","891.94","1910.74","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","WELLPOINT [1015]","HB CH WELLPOINT","2982.63","77.91","","1829.79","1561.50","2617.12","88","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1359.46","1201.30","1689.00","61","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1718.92","1718.92","1718.92","1 through 10","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ LG TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3003.30","78.45","","1910.74","1019.06","2344.84","74","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","AETNA [1001]","HB CH AETNA HMO / PPO","2231.90","58.3","","1530.90","1160.93","1884.08","89","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2029.00","53","","5253.92","5253.92","5253.92","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2220.41","58","","12181.47","12181.47","12181.47","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2392.69","62.5","","1350.68","1350.68","1350.68","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.68","44.45","","1910.74","891.94","1910.74","1 through 10","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","WELLPOINT [1015]","HB CH WELLPOINT","2982.63","77.91","","1829.79","1561.50","2617.12","88","1701.68","2982.63","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1359.46","1201.30","1689.00","61","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1718.92","1718.92","1718.92","1 through 10","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ MED TIBIAL PERSONA TRABECULAR METAL REV CENTRAL","SUP-ITM-10268200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3003.30","78.45","","1910.74","1019.06","2344.84","74","1914.15","3003.3","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"KNEE HEAD SM FEMORAL JOURNEY TROCHLEAR COMPETITOR TITANIUM RIGHT","SUP-ITM-10020616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1530.90","1160.93","1884.08","89","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","5253.92","5253.92","5253.92","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","869.65","58","","12181.47","12181.47","12181.47","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.13","62.5","","1350.68","1350.68","1350.68","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.48","44.45","","1910.74","891.94","1910.74","1 through 10","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","1829.79","1561.50","2617.12","88","666.48","1168.18","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1359.46","1201.30","1689.00","61","749.7","1176.28","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.14","59.3","","1718.92","1718.92","1718.92","1 through 10","749.7","1176.28","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","1910.74","1019.06","2344.84","74","749.7","1176.28","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","AETNA [1001]","HB CH AETNA HMO / PPO","1830.94","58.3","","1530.90","1160.93","1884.08","89","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1664.49","53","","5253.92","5253.92","5253.92","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1821.52","58","","12181.47","12181.47","12181.47","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1962.84","62.5","","1350.68","1350.68","1350.68","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1395.97","44.45","","1910.74","891.94","1910.74","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","WELLPOINT [1015]","HB CH WELLPOINT","2446.80","77.91","","1829.79","1561.50","2617.12","88","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1359.46","1201.30","1689.00","61","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2463.76","78.45","","1910.74","1019.06","2344.84","74","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","AETNA [1001]","HB CH AETNA HMO / PPO","835.58","58.3","","1530.90","1160.93","1884.08","89","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","759.62","53","","5253.92","5253.92","5253.92","1 through 10","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","831.29","58","","12181.47","12181.47","12181.47","1 through 10","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","895.78","62.5","","1350.68","1350.68","1350.68","1 through 10","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","637.08","44.45","","1910.74","891.94","1910.74","1 through 10","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","WELLPOINT [1015]","HB CH WELLPOINT","1116.65","77.91","","1829.79","1561.50","2617.12","88","637.08","1116.65","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","849.92","59.3","","1359.46","1201.30","1689.00","61","716.63","1124.38","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","849.92","59.3","","1718.92","1718.92","1718.92","1 through 10","716.63","1124.38","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1124.38","78.45","","1910.74","1019.06","2344.84","74","716.63","1124.38","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","AETNA [1001]","HB CH AETNA HMO / PPO","1830.94","58.3","","1530.90","1160.93","1884.08","89","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1664.49","53","","5253.92","5253.92","5253.92","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1821.52","58","","12181.47","12181.47","12181.47","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1962.84","62.5","","1350.68","1350.68","1350.68","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1395.97","44.45","","1910.74","891.94","1910.74","1 through 10","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","WELLPOINT [1015]","HB CH WELLPOINT","2446.80","77.91","","1829.79","1561.50","2617.12","88","1395.97","2446.8","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1359.46","1201.30","1689.00","61","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 12MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2463.76","78.45","","1910.74","1019.06","2344.84","74","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","1530.90","1160.93","1884.08","89","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","5253.92","5253.92","5253.92","1 through 10","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2726.00","58","","12181.47","12181.47","12181.47","1 through 10","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2937.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2089.15","44.45","","1910.74","891.94","1910.74","1 through 10","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","1829.79","1561.50","2617.12","88","2089.15","3661.77","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1359.46","1201.30","1689.00","61","2350","3687.15","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1718.92","1718.92","1718.92","1 through 10","2350","3687.15","percent of total billed charges",""
"KNEE IMPLANT 140MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10024895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","1910.74","1019.06","2344.84","74","2350","3687.15","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","AETNA [1001]","HB CH AETNA HMO / PPO","1463.65","58.3","","1530.90","1160.93","1884.08","89","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.59","53","","5253.92","5253.92","5253.92","1 through 10","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1456.12","58","","12181.47","12181.47","12181.47","1 through 10","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1569.09","62.5","","1350.68","1350.68","1350.68","1 through 10","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1115.94","44.45","","1910.74","891.94","1910.74","1 through 10","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","WELLPOINT [1015]","HB CH WELLPOINT","1955.97","77.91","","1829.79","1561.50","2617.12","88","1115.94","1955.97","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2510.55","1882.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1488.76","59.3","","1359.46","1201.30","1689.00","61","1255.28","1969.53","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2510.55","1882.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1488.76","59.3","","1718.92","1718.92","1718.92","1 through 10","1255.28","1969.53","percent of total billed charges",""
"KNEE IMPLANT 14MM SIZE 5 TO6 ARTICULAR SURFACE NEXGEN LCCK STRIPE GH 08 BX/1EA","SUP-ITM-10025690","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2510.55","1882.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.53","78.45","","1910.74","1019.06","2344.84","74","1255.28","1969.53","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","1530.90","1160.93","1884.08","89","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","5253.92","5253.92","5253.92","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","487.20","58","","12181.47","12181.47","12181.47","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","525.00","62.5","","1350.68","1350.68","1350.68","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","1910.74","891.94","1910.74","1 through 10","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","1829.79","1561.50","2617.12","88","373.38","654.44","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","1359.46","1201.30","1689.00","61","420","658.98","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","498.12","59.3","","1718.92","1718.92","1718.92","1 through 10","420","658.98","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","1910.74","1019.06","2344.84","74","420","658.98","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1530.90","1160.93","1884.08","89","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","5253.92","5253.92","5253.92","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","12181.47","12181.47","12181.47","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1910.74","891.94","1910.74","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","1829.79","1561.50","2617.12","88","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1359.46","1201.30","1689.00","61","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1718.92","1718.92","1718.92","1 through 10","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1910.74","1019.06","2344.84","74","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","AETNA [1001]","HB CH AETNA HMO / PPO","780.05","58.3","","1530.90","1160.93","1884.08","89","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","709.14","53","","5253.92","5253.92","5253.92","1 through 10","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","776.04","58","","12181.47","12181.47","12181.47","1 through 10","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","836.25","62.5","","1350.68","1350.68","1350.68","1 through 10","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.74","44.45","","1910.74","891.94","1910.74","1 through 10","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","WELLPOINT [1015]","HB CH WELLPOINT","1042.44","77.91","","1829.79","1561.50","2617.12","88","594.74","1042.44","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.43","59.3","","1359.46","1201.30","1689.00","61","669","1049.66","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","793.43","59.3","","1718.92","1718.92","1718.92","1 through 10","669","1049.66","percent of total billed charges",""
"KNEE IMPLANT 8.0MM SIZE 5 COMPONENT FEMORAL NEXGEN ARTICULAR SURFACE POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX","SUP-ITM-10016526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.66","78.45","","1910.74","1019.06","2344.84","74","669","1049.66","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1530.90","1160.93","1884.08","89","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","5253.92","5253.92","5253.92","1 through 10","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.00","58","","12181.47","12181.47","12181.47","1 through 10","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.50","62.5","","1350.68","1350.68","1350.68","1 through 10","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","1910.74","891.94","1910.74","1 through 10","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","1829.79","1561.50","2617.12","88","400.05","701.19","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1359.46","1201.30","1689.00","61","450","706.05","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.70","59.3","","1718.92","1718.92","1718.92","1 through 10","450","706.05","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1910.74","1019.06","2344.84","74","450","706.05","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1530.90","1160.93","1884.08","89","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","5253.92","5253.92","5253.92","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2752.68","58","","12181.47","12181.47","12181.47","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2966.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2109.60","44.45","","1910.74","891.94","1910.74","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","1829.79","1561.50","2617.12","88","2109.6","3697.61","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1359.46","1201.30","1689.00","61","2373","3723.24","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2373","3723.24","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR RT SIZE D CS/1BX/1EA","SUP-ITM-10009554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","1910.74","1019.06","2344.84","74","2373","3723.24","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN CR FLEX GSF TITANIUM PRECOAT CRUCIATE RETAINING FEMALE LT SIZE E MINUS","SUP-ITM-10018646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","464.71","67.87","1012.10","221","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","293.04","293.04","293.04","11","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","983.89","983.89","983.89","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2131.50","58","","677.18","677.18","677.18","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2296.88","62.5","","46.58","46.58","46.58","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","747.15","747.15","747.15","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","1141.67","481.21","1141.67","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","76.54","76.54","76.54","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","273.64","94.28","1367.51","138","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","720.78","230.14","2010.94","427","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2179.28","59.3","","344.45","344.45","344.45","1 through 10","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","1120.13","1120.13","1120.13","1 through 10","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN LPS FLEX TIVANIUM PRECOAT CRUCIATE RETAINING LT SIZE F","SUP-ITM-10074333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","456.17","105.33","1284.66","242","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 3.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW RIGHT","SUP-ITM-10101423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 6 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","AETNA [1001]","HB CH AETNA HMO / PPO","1428.93","58.3","","1530.90","1160.93","1884.08","89","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1299.03","53","","5253.92","5253.92","5253.92","1 through 10","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1421.58","58","","12181.47","12181.47","12181.47","1 through 10","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1531.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1089.47","44.45","","1910.74","891.94","1910.74","1 through 10","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","WELLPOINT [1015]","HB CH WELLPOINT","1909.57","77.91","","1829.79","1561.50","2617.12","88","1089.47","1909.57","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1453.44","59.3","","1359.46","1201.30","1689.00","61","1225.5","1922.81","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1453.44","59.3","","1718.92","1718.92","1718.92","1 through 10","1225.5","1922.81","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1922.81","78.45","","1910.74","1019.06","2344.84","74","1225.5","1922.81","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","464.71","67.87","1012.10","221","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","293.04","293.04","293.04","11","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","983.89","983.89","983.89","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","677.18","677.18","677.18","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","46.58","46.58","46.58","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","747.15","747.15","747.15","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1141.67","481.21","1141.67","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","76.54","76.54","76.54","1 through 10","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","273.64","94.28","1367.51","138","1466.85","2571.03","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","720.78","230.14","2010.94","427","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","344.45","344.45","344.45","1 through 10","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1120.13","1120.13","1120.13","1 through 10","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SIZE H 70.5X76.5MM COMPONENT FEMORAL NEXGEN LPS PRECOAT MACRO LEFT","SUP-ITM-10018102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","456.17","105.33","1284.66","242","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1530.90","1160.93","1884.08","89","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","5253.92","5253.92","5253.92","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2131.50","58","","12181.47","12181.47","12181.47","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2296.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","1910.74","891.94","1910.74","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","1829.79","1561.50","2617.12","88","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1359.46","1201.30","1689.00","61","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","1910.74","1019.06","2344.84","74","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1530.90","1160.93","1884.08","89","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","5253.92","5253.92","5253.92","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2131.50","58","","12181.47","12181.47","12181.47","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2296.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1633.54","44.45","","1910.74","891.94","1910.74","1 through 10","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","1829.79","1561.50","2617.12","88","1633.54","2863.19","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1359.46","1201.30","1689.00","61","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1718.92","1718.92","1718.92","1 through 10","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","1910.74","1019.06","2344.84","74","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021734","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL TRIATHLON PKR COBALT LT MEDIAL RT LATERAL","SUP-ITM-10027669","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","464.71","67.87","1012.10","221","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","293.04","293.04","293.04","11","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","983.89","983.89","983.89","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","677.18","677.18","677.18","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","46.58","46.58","46.58","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","747.15","747.15","747.15","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1141.67","481.21","1141.67","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","76.54","76.54","76.54","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","273.64","94.28","1367.51","138","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","720.78","230.14","2010.94","427","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","344.45","344.45","344.45","1 through 10","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1120.13","1120.13","1120.13","1 through 10","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","456.17","105.33","1284.66","242","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1530.90","1160.93","1884.08","89","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","5253.92","5253.92","5253.92","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","12181.47","12181.47","12181.47","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","1910.74","891.94","1910.74","1 through 10","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1829.79","1561.50","2617.12","88","1778","3116.4","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1359.46","1201.30","1689.00","61","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1718.92","1718.92","1718.92","1 through 10","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1910.74","1019.06","2344.84","74","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1530.90","1160.93","1884.08","89","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","5253.92","5253.92","5253.92","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","12181.47","12181.47","12181.47","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","1910.74","891.94","1910.74","1 through 10","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1829.79","1561.50","2617.12","88","1944.69","3408.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1359.46","1201.30","1689.00","61","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM NARROW CRUCIATE RETAINING LT N","SUP-ITM-10133134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1910.74","1019.06","2344.84","74","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1530.90","1160.93","1884.08","89","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","5253.92","5253.92","5253.92","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2880.57","58","","12181.47","12181.47","12181.47","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3104.06","62.5","","1350.68","1350.68","1350.68","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2207.61","44.45","","1910.74","891.94","1910.74","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","1829.79","1561.50","2617.12","88","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1359.46","1201.30","1689.00","61","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","1910.74","1019.06","2344.84","74","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1530.90","1160.93","1884.08","89","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","5253.92","5253.92","5253.92","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","12181.47","12181.47","12181.47","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1910.74","891.94","1910.74","1 through 10","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","1829.79","1561.50","2617.12","88","1555.75","2726.85","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1359.46","1201.30","1689.00","61","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1718.92","1718.92","1718.92","1 through 10","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1910.74","1019.06","2344.84","74","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1530.90","1160.93","1884.08","89","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","5253.92","5253.92","5253.92","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2880.57","58","","12181.47","12181.47","12181.47","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3104.06","62.5","","1350.68","1350.68","1350.68","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2207.61","44.45","","1910.74","891.94","1910.74","1 through 10","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","1829.79","1561.50","2617.12","88","2207.61","3869.4","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1359.46","1201.30","1689.00","61","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1718.92","1718.92","1718.92","1 through 10","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","1910.74","1019.06","2344.84","74","2483.25","3896.22","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","AETNA [1001]","HB CH AETNA HMO / PPO","1538.25","58.3","","1530.90","1160.93","1884.08","89","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1398.41","53","","5253.92","5253.92","5253.92","1 through 10","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1530.33","58","","12181.47","12181.47","12181.47","1 through 10","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1649.06","62.5","","1350.68","1350.68","1350.68","1 through 10","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.81","44.45","","1910.74","891.94","1910.74","1 through 10","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","both","","","2638.50","1978.87","WELLPOINT [1015]","HB CH WELLPOINT","2055.66","77.91","","1829.79","1561.50","2617.12","88","1172.81","2055.66","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2638.50","1978.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","1564.63","59.3","","1359.46","1201.30","1689.00","61","1319.25","2069.9","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2638.50","1978.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1564.63","59.3","","1718.92","1718.92","1718.92","1 through 10","1319.25","2069.9","percent of total billed charges",""
"KNEE INSERT 11MM LARGE TIBIAL DURACON DURATION COBALT CHROMIUM ALLOY STABILIZING LIPPED POSTERIOR","SUP-ITM-10028286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2638.50","1978.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2069.90","78.45","","1910.74","1019.06","2344.84","74","1319.25","2069.9","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1530.90","1160.93","1884.08","89","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","5253.92","5253.92","5253.92","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1569.48","58","","12181.47","12181.47","12181.47","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1691.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.82","44.45","","1910.74","891.94","1910.74","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","1829.79","1561.50","2617.12","88","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1359.46","1201.30","1689.00","61","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1718.92","1718.92","1718.92","1 through 10","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 12.5MM SIZE 5.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","1910.74","1019.06","2344.84","74","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","AETNA [1001]","HB CH AETNA HMO / PPO","1393.95","58.3","","1530.90","1160.93","1884.08","89","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.23","53","","5253.92","5253.92","5253.92","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1386.78","58","","12181.47","12181.47","12181.47","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1494.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.80","44.45","","1910.74","891.94","1910.74","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","WELLPOINT [1015]","HB CH WELLPOINT","1862.83","77.91","","1829.79","1561.50","2617.12","88","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1359.46","1201.30","1689.00","61","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1718.92","1718.92","1718.92","1 through 10","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 13MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10057460","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1875.74","78.45","","1910.74","1019.06","2344.84","74","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","AETNA [1001]","HB CH AETNA HMO / PPO","886.74","58.3","","1530.90","1160.93","1884.08","89","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","806.13","53","","5253.92","5253.92","5253.92","1 through 10","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","882.18","58","","12181.47","12181.47","12181.47","1 through 10","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","950.63","62.5","","1350.68","1350.68","1350.68","1 through 10","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","676.08","44.45","","1910.74","891.94","1910.74","1 through 10","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","WELLPOINT [1015]","HB CH WELLPOINT","1185.01","77.91","","1829.79","1561.50","2617.12","88","676.08","1185.01","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1521.00","1140.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.95","59.3","","1359.46","1201.30","1689.00","61","760.5","1193.22","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1521.00","1140.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","901.95","59.3","","1718.92","1718.92","1718.92","1 through 10","760.5","1193.22","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1521.00","1140.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1193.22","78.45","","1910.74","1019.06","2344.84","74","760.5","1193.22","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","AETNA [1001]","HB CH AETNA HMO / PPO","1393.95","58.3","","1530.90","1160.93","1884.08","89","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.23","53","","5253.92","5253.92","5253.92","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1386.78","58","","12181.47","12181.47","12181.47","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1494.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.80","44.45","","1910.74","891.94","1910.74","1 through 10","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","WELLPOINT [1015]","HB CH WELLPOINT","1862.83","77.91","","1829.79","1561.50","2617.12","88","1062.8","1862.83","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1359.46","1201.30","1689.00","61","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1718.92","1718.92","1718.92","1 through 10","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1875.74","78.45","","1910.74","1019.06","2344.84","74","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","464.71","67.87","1012.10","221","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","293.04","293.04","293.04","11","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","983.89","983.89","983.89","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","828.24","58","","677.18","677.18","677.18","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","892.50","62.5","","46.58","46.58","46.58","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","747.15","747.15","747.15","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","1141.67","481.21","1141.67","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","76.54","76.54","76.54","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","273.64","94.28","1367.51","138","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","720.78","230.14","2010.94","427","714","1120.27","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","846.80","59.3","","344.45","344.45","344.45","1 through 10","714","1120.27","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","1120.13","1120.13","1120.13","1 through 10","714","1120.27","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","456.17","105.33","1284.66","242","714","1120.27","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1530.90","1160.93","1884.08","89","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","5253.92","5253.92","5253.92","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1569.48","58","","12181.47","12181.47","12181.47","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1691.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.82","44.45","","1910.74","891.94","1910.74","1 through 10","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","1829.79","1561.50","2617.12","88","1202.82","2108.24","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1359.46","1201.30","1689.00","61","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1718.92","1718.92","1718.92","1 through 10","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 3 10MM SIZE IMPLANT TC TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10036265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","1910.74","1019.06","2344.84","74","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1530.90","1160.93","1884.08","89","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","5253.92","5253.92","5253.92","1 through 10","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1743.48","58","","12181.47","12181.47","12181.47","1 through 10","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1878.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.17","44.45","","1910.74","891.94","1910.74","1 through 10","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","1829.79","1561.50","2617.12","88","1336.17","2341.97","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1359.46","1201.30","1689.00","61","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1718.92","1718.92","1718.92","1 through 10","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 5 11MM SIZE 4 LEGION HK POLYETHYLENE GUIDED MOTION RIGHT","SUP-ITM-10106899","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","1910.74","1019.06","2344.84","74","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1530.90","1160.93","1884.08","89","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","5253.92","5253.92","5253.92","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","828.24","58","","12181.47","12181.47","12181.47","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","892.50","62.5","","1350.68","1350.68","1350.68","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","1910.74","891.94","1910.74","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","1829.79","1561.50","2617.12","88","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1359.46","1201.30","1689.00","61","714","1120.27","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","846.80","59.3","","1718.92","1718.92","1718.92","1 through 10","714","1120.27","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","1910.74","1019.06","2344.84","74","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1530.90","1160.93","1884.08","89","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","5253.92","5253.92","5253.92","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","828.24","58","","12181.47","12181.47","12181.47","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","892.50","62.5","","1350.68","1350.68","1350.68","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","1910.74","891.94","1910.74","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","1829.79","1561.50","2617.12","88","634.75","1112.55","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1359.46","1201.30","1689.00","61","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","846.80","59.3","","1718.92","1718.92","1718.92","1 through 10","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 13MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10031408","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","1910.74","1019.06","2344.84","74","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","AETNA [1001]","HB CH AETNA HMO / PPO","99.17","58.3","","1530.90","1160.93","1884.08","89","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.15","53","","5253.92","5253.92","5253.92","1 through 10","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","98.66","58","","12181.47","12181.47","12181.47","1 through 10","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","106.31","62.5","","1350.68","1350.68","1350.68","1 through 10","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.61","44.45","","1910.74","891.94","1910.74","1 through 10","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","WELLPOINT [1015]","HB CH WELLPOINT","132.52","77.91","","1829.79","1561.50","2617.12","88","75.61","132.52","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.87","59.3","","1359.46","1201.30","1689.00","61","85.05","133.44","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","100.87","59.3","","1718.92","1718.92","1718.92","1 through 10","85.05","133.44","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.44","78.45","","1910.74","1019.06","2344.84","74","85.05","133.44","percent of total billed charges",""
"Knee Joint Replacement,MAJOR","302","DRG","","","","","","","","inpatient","","","74908.72","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","38472.3354","","Fee schedule rate ($53,109.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38472.3354","53109.30","53109.30","1 through 10","14476.57","87629.52","case rate",""
"Knee Joint Replacement,MINOR","302","DRG","","","","","","","","inpatient","","","38472.76","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","36301.03","","Fee schedule rate ($36,301.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36301.03","36301.03","36301.03","1 through 10","14476.57","87629.52","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","42113.49","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","38472.3354","","Fee schedule rate ($42,648.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38472.3354","42648.46","42648.46","1 through 10","14476.57","87629.52","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","42113.49","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","38786.43","","Fee schedule rate ($38,786.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38786.43","38786.43","38786.43","1 through 10","14476.57","87629.52","case rate",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1530.90","1160.93","1884.08","89","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","5253.92","5253.92","5253.92","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","828.24","58","","12181.47","12181.47","12181.47","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","892.50","62.5","","1350.68","1350.68","1350.68","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","1910.74","891.94","1910.74","1 through 10","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","1829.79","1561.50","2617.12","88","634.75","1112.55","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1359.46","1201.30","1689.00","61","714","1120.27","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","846.80","59.3","","1718.92","1718.92","1718.92","1 through 10","714","1120.27","percent of total billed charges",""
"KNEE LEGION CROSSLINKED 13MM SIZE 1-2 INSERT POLYETHYLENE DISHED TIBIAL","SUP-ITM-10121616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","1910.74","1019.06","2344.84","74","714","1120.27","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","AETNA [1001]","HB CH AETNA HMO / PPO","3817.37","58.3","","1530.90","1160.93","1884.08","89","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3470.33","53","","5253.92","5253.92","5253.92","1 through 10","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3797.72","58","","12181.47","12181.47","12181.47","1 through 10","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4092.38","62.5","","1350.68","1350.68","1350.68","1 through 10","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2910.50","44.45","","1910.74","891.94","1910.74","1 through 10","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","WELLPOINT [1015]","HB CH WELLPOINT","5101.39","77.91","","1829.79","1561.50","2617.12","88","2910.5","5101.39","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1359.46","1201.30","1689.00","61","3273.9","5136.75","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1718.92","1718.92","1718.92","1 through 10","3273.9","5136.75","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5136.75","78.45","","1910.74","1019.06","2344.84","74","3273.9","5136.75","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","AETNA [1001]","HB CH AETNA HMO / PPO","1956.27","58.3","","464.71","67.87","1012.10","221","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1956.27","58.3","","293.04","293.04","293.04","11","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1778.43","53","","983.89","983.89","983.89","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1946.21","58","","677.18","677.18","677.18","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2097.21","62.5","","46.58","46.58","46.58","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2449.54","73","","747.15","747.15","747.15","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1491.53","44.45","","1141.67","481.21","1141.67","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1491.53","44.45","","76.54","76.54","76.54","1 through 10","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3355.53","2516.65","WELLPOINT [1015]","HB CH WELLPOINT","2614.29","77.91","","273.64","94.28","1367.51","138","1491.53","2614.29","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3355.53","2516.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1989.83","59.3","","720.78","230.14","2010.94","427","1677.77","2632.41","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3355.53","2516.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1989.83","59.3","","344.45","344.45","344.45","1 through 10","1677.77","2632.41","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3355.53","2516.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2632.41","78.45","","1120.13","1120.13","1120.13","1 through 10","1677.77","2632.41","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3355.53","2516.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2632.41","78.45","","456.17","105.33","1284.66","242","1677.77","2632.41","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","AETNA [1001]","HB CH AETNA HMO / PPO","1476.10","58.3","","464.71","67.87","1012.10","221","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1476.10","58.3","","293.04","293.04","293.04","11","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1341.91","53","","983.89","983.89","983.89","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1468.51","58","","677.18","677.18","677.18","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1582.44","62.5","","46.58","46.58","46.58","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1848.29","73","","747.15","747.15","747.15","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1125.43","44.45","","1141.67","481.21","1141.67","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1125.43","44.45","","76.54","76.54","76.54","1 through 10","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.91","1898.93","WELLPOINT [1015]","HB CH WELLPOINT","1972.61","77.91","","273.64","94.28","1367.51","138","1125.43","1972.61","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.91","1898.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","1501.42","59.3","","720.78","230.14","2010.94","427","1265.96","1986.28","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.91","1898.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1501.42","59.3","","344.45","344.45","344.45","1 through 10","1265.96","1986.28","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.91","1898.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1986.28","78.45","","1120.13","1120.13","1120.13","1 through 10","1265.96","1986.28","percent of total billed charges",""
"KNEE PLATE 3.5X69MM 1 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10095151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.91","1898.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1986.28","78.45","","456.17","105.33","1284.66","242","1265.96","1986.28","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","1530.90","1160.93","1884.08","89","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","643.95","53","","5253.92","5253.92","5253.92","1 through 10","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","704.70","58","","12181.47","12181.47","12181.47","1 through 10","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","759.38","62.5","","1350.68","1350.68","1350.68","1 through 10","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","1910.74","891.94","1910.74","1 through 10","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","1829.79","1561.50","2617.12","88","540.07","946.61","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","1359.46","1201.30","1689.00","61","607.5","953.17","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","720.50","59.3","","1718.92","1718.92","1718.92","1 through 10","607.5","953.17","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","1910.74","1019.06","2344.84","74","607.5","953.17","percent of total billed charges",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","58833.23","44124.92","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","19920.24","","Case rate ($19,920.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,611.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,753.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,326.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $18,535.75. The transfer operating threshold is the transfer adjustment factor * $18,611.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.49. The transfer capital threshold is the transfer adjustment factor * $1,384.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18289.50","18289.50","18289.50","1 through 10","17754.79","20973.5801","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","58833.23","44124.92","MEDICARE [2001]","HB NWH MEDICARE","19920.24","","Case rate ($19,920.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,611.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,753.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,326.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $18,535.75. The transfer operating threshold is the transfer adjustment factor * $18,611.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.49. The transfer capital threshold is the transfer adjustment factor * $1,384.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20242.23","20242.23","20242.23","1 through 10","17754.79","20973.5801","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","58833.23","44124.92","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17754.79","","Case rate ($18,117.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,611.22, add-ons for qualifying new technology services are included. If operating cost exceeds $63,753.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,326.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,732.64. The transfer operating threshold is the transfer adjustment factor * $18,611.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.49. The transfer capital threshold is the transfer adjustment factor * $1,384.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","56880.73","56880.73","56880.73","1 through 10","17754.79","20973.5801","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","34551.30","25913.47","MEDICARE [2001]","HB NWH MEDICARE","15325.62","","Case rate ($15,325.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,743.57, add-ons for qualifying new technology services are included. If operating cost exceeds $60,885.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,113.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,154.45. The transfer operating threshold is the transfer adjustment factor * $15,743.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,171.17. The transfer capital threshold is the transfer adjustment factor * $1,171.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18758.11","18758.11","18791.83","1 through 10","15019.11","18157.76","other","Inpatient Replacement Plans DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","27948.94","20961.70","MEDICARE [2001]","HB NWH MEDICARE","9675.87","","Case rate ($9,675.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,939.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,082.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,681.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,936.45. The transfer operating threshold is the transfer adjustment factor * $9,939.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.42. The transfer capital threshold is the transfer adjustment factor * $739.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11819.50","11819.50","11840.74","1 through 10","9482.35","11463.95","other","Inpatient Replacement Plans DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","27948.94","20961.70","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9482.35","","Case rate ($9,675.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,939.75, add-ons for qualifying new technology services are included. If operating cost exceeds $55,082.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,681.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,936.45. The transfer operating threshold is the transfer adjustment factor * $9,939.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.42. The transfer capital threshold is the transfer adjustment factor * $739.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10573.28","10573.28","10573.28","1 through 10","9482.35","11463.95","other","Inpatient DRG"
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","AETNA [1001]","HB CH AETNA HMO / PPO","2011.35","58.3","","1530.90","1160.93","1884.08","89","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1828.50","53","","5253.92","5253.92","5253.92","1 through 10","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2001.00","58","","12181.47","12181.47","12181.47","1 through 10","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2156.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.53","44.45","","1910.74","891.94","1910.74","1 through 10","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","WELLPOINT [1015]","HB CH WELLPOINT","2687.90","77.91","","1829.79","1561.50","2617.12","88","1533.53","2687.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3450.00","2587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2045.85","59.3","","1359.46","1201.30","1689.00","61","1725","2706.53","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3450.00","2587.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2045.85","59.3","","1718.92","1718.92","1718.92","1 through 10","1725","2706.53","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3450.00","2587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2706.53","78.45","","1910.74","1019.06","2344.84","74","1725","2706.53","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1530.90","1160.93","1884.08","89","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","5253.92","5253.92","5253.92","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","12181.47","12181.47","12181.47","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","1350.68","1350.68","1350.68","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1910.74","891.94","1910.74","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","1829.79","1561.50","2617.12","88","733.43","1285.52","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1359.46","1201.30","1689.00","61","825","1294.43","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","1718.92","1718.92","1718.92","1 through 10","825","1294.43","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1910.74","1019.06","2344.84","74","825","1294.43","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"KNEE STEM 127X15MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT","SUP-ITM-10005473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1530.90","1160.93","1884.08","89","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","5253.92","5253.92","5253.92","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2610.00","58","","12181.47","12181.47","12181.47","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2812.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2000.25","44.45","","1910.74","891.94","1910.74","1 through 10","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","1829.79","1561.50","2617.12","88","2000.25","3505.95","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1359.46","1201.30","1689.00","61","2250","3530.25","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1718.92","1718.92","1718.92","1 through 10","2250","3530.25","percent of total billed charges",""
"KNEE STEM 127X17MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY CS/1BX/1EA","SUP-ITM-10015145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","1910.74","1019.06","2344.84","74","2250","3530.25","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","1530.90","1160.93","1884.08","89","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.18","53","","5253.92","5253.92","5253.92","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","525.48","58","","12181.47","12181.47","12181.47","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","566.25","62.5","","1350.68","1350.68","1350.68","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.72","44.45","","1910.74","891.94","1910.74","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","1829.79","1561.50","2617.12","88","402.72","705.86","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","1359.46","1201.30","1689.00","61","453","710.76","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","537.26","59.3","","1718.92","1718.92","1718.92","1 through 10","453","710.76","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","1910.74","1019.06","2344.84","74","453","710.76","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","AETNA [1001]","HB CH AETNA HMO / PPO","1280.01","58.3","","1530.90","1160.93","1884.08","89","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1163.64","53","","5253.92","5253.92","5253.92","1 through 10","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1273.42","58","","12181.47","12181.47","12181.47","1 through 10","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1372.22","62.5","","1350.68","1350.68","1350.68","1 through 10","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.92","44.45","","1910.74","891.94","1910.74","1 through 10","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","WELLPOINT [1015]","HB CH WELLPOINT","1710.55","77.91","","1829.79","1561.50","2617.12","88","975.92","1710.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2195.55","1646.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","1301.96","59.3","","1359.46","1201.30","1689.00","61","1097.78","1722.41","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2195.55","1646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1301.96","59.3","","1718.92","1718.92","1718.92","1 through 10","1097.78","1722.41","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2195.55","1646.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1722.41","78.45","","1910.74","1019.06","2344.84","74","1097.78","1722.41","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1530.90","1160.93","1884.08","89","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","5253.92","5253.92","5253.92","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","957.00","58","","12181.47","12181.47","12181.47","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1031.25","62.5","","1350.68","1350.68","1350.68","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","1910.74","891.94","1910.74","1 through 10","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","1829.79","1561.50","2617.12","88","733.43","1285.52","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1359.46","1201.30","1689.00","61","825","1294.43","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","978.45","59.3","","1718.92","1718.92","1718.92","1 through 10","825","1294.43","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","1910.74","1019.06","2344.84","74","825","1294.43","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","AETNA [1001]","HB CH AETNA HMO / PPO","1689.53","58.3","","1530.90","1160.93","1884.08","89","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1535.94","53","","5253.92","5253.92","5253.92","1 through 10","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1680.84","58","","12181.47","12181.47","12181.47","1 through 10","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1811.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1288.16","44.45","","1910.74","891.94","1910.74","1 through 10","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","WELLPOINT [1015]","HB CH WELLPOINT","2257.83","77.91","","1829.79","1561.50","2617.12","88","1288.16","2257.83","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1359.46","1201.30","1689.00","61","1449","2273.48","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1718.92","1718.92","1718.92","1 through 10","1449","2273.48","percent of total billed charges",""
"KNEE STEM 15X150MM FEMORAL TRIATHLON TS PRESS FIX TITANIUM CEMENTLESS FLUTE","SUP-ITM-10079244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2273.48","78.45","","1910.74","1019.06","2344.84","74","1449","2273.48","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","1530.90","1160.93","1884.08","89","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.18","53","","5253.92","5253.92","5253.92","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","525.48","58","","12181.47","12181.47","12181.47","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","566.25","62.5","","1350.68","1350.68","1350.68","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.72","44.45","","1910.74","891.94","1910.74","1 through 10","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","1829.79","1561.50","2617.12","88","402.72","705.86","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","1359.46","1201.30","1689.00","61","453","710.76","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","537.26","59.3","","1718.92","1718.92","1718.92","1 through 10","453","710.76","percent of total billed charges",""
"KNEE STEM 16MMX160 FEMORAL LEGION COBALT CEMENTED","SUP-ITM-10106898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","1910.74","1019.06","2344.84","74","453","710.76","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1530.90","1160.93","1884.08","89","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","5253.92","5253.92","5253.92","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2752.68","58","","12181.47","12181.47","12181.47","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2966.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2109.60","44.45","","1910.74","891.94","1910.74","1 through 10","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","1829.79","1561.50","2617.12","88","2109.6","3697.61","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1359.46","1201.30","1689.00","61","2373","3723.24","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1718.92","1718.92","1718.92","1 through 10","2373","3723.24","percent of total billed charges",""
"KNEE STEM 67.5MM FEMORAL VANGUARD SSK 360 REVISION SY LEFT","SUP-ITM-10117744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","1910.74","1019.06","2344.84","74","2373","3723.24","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","AETNA [1001]","HB CH AETNA HMO / PPO","1774.01","58.3","","1530.90","1160.93","1884.08","89","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1612.74","53","","5253.92","5253.92","5253.92","1 through 10","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1764.88","58","","12181.47","12181.47","12181.47","1 through 10","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1901.81","62.5","","1350.68","1350.68","1350.68","1 through 10","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1352.57","44.45","","1910.74","891.94","1910.74","1 through 10","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","WELLPOINT [1015]","HB CH WELLPOINT","2370.72","77.91","","1829.79","1561.50","2617.12","88","1352.57","2370.72","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3042.90","2282.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","1804.44","59.3","","1359.46","1201.30","1689.00","61","1521.45","2387.16","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3042.90","2282.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1804.44","59.3","","1718.92","1718.92","1718.92","1 through 10","1521.45","2387.16","percent of total billed charges",""
"KNEE STEM EXTENSION L 80MM OD 18 TIBIA VANGUARD 360 COBALT ALLOY SPLINED","SUP-ITM-10076969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3042.90","2282.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2387.16","78.45","","1910.74","1019.06","2344.84","74","1521.45","2387.16","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1530.90","1160.93","1884.08","89","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","5253.92","5253.92","5253.92","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2031.62","58","","12181.47","12181.47","12181.47","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2189.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","1910.74","891.94","1910.74","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","1829.79","1561.50","2617.12","88","1556.99","2729.03","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1359.46","1201.30","1689.00","61","1751.4","2747.95","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1718.92","1718.92","1718.92","1 through 10","1751.4","2747.95","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","1910.74","1019.06","2344.84","74","1751.4","2747.95","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","464.71","67.87","1012.10","221","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","293.04","293.04","293.04","11","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","983.89","983.89","983.89","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1151.01","58","","677.18","677.18","677.18","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1240.31","62.5","","46.58","46.58","46.58","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","747.15","747.15","747.15","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","1141.67","481.21","1141.67","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","76.54","76.54","76.54","1 through 10","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","273.64","94.28","1367.51","138","882.11","1546.12","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","720.78","230.14","2010.94","427","992.25","1556.84","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1176.81","59.3","","344.45","344.45","344.45","1 through 10","992.25","1556.84","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","1120.13","1120.13","1120.13","1 through 10","992.25","1556.84","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","456.17","105.33","1284.66","242","992.25","1556.84","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1530.90","1160.93","1884.08","89","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","5253.92","5253.92","5253.92","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","812.58","58","","12181.47","12181.47","12181.47","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","875.63","62.5","","1350.68","1350.68","1350.68","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.74","44.45","","1910.74","891.94","1910.74","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","1829.79","1561.50","2617.12","88","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1359.46","1201.30","1689.00","61","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","830.79","59.3","","1718.92","1718.92","1718.92","1 through 10","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 5 SCREW ON LEGION","SUP-ITM-10021269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","1910.74","1019.06","2344.84","74","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1530.90","1160.93","1884.08","89","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","5253.92","5253.92","5253.92","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","812.58","58","","12181.47","12181.47","12181.47","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","875.63","62.5","","1350.68","1350.68","1350.68","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.74","44.45","","1910.74","891.94","1910.74","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","1829.79","1561.50","2617.12","88","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1359.46","1201.30","1689.00","61","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","830.79","59.3","","1718.92","1718.92","1718.92","1 through 10","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 7 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10018352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","1910.74","1019.06","2344.84","74","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","464.71","67.87","1012.10","221","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.13","58.3","","293.04","293.04","293.04","11","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","983.89","983.89","983.89","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2031.62","58","","677.18","677.18","677.18","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2189.25","62.5","","46.58","46.58","46.58","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.04","73","","747.15","747.15","747.15","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","1141.67","481.21","1141.67","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","76.54","76.54","76.54","1 through 10","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","273.64","94.28","1367.51","138","1556.99","2729.03","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","720.78","230.14","2010.94","427","1751.4","2747.95","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2077.16","59.3","","344.45","344.45","344.45","1 through 10","1751.4","2747.95","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","1120.13","1120.13","1120.13","1 through 10","1751.4","2747.95","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","456.17","105.33","1284.66","242","1751.4","2747.95","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1530.90","1160.93","1884.08","89","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","5253.92","5253.92","5253.92","1 through 10","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1084.02","58","","12181.47","12181.47","12181.47","1 through 10","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1168.13","62.5","","1350.68","1350.68","1350.68","1 through 10","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.77","44.45","","1910.74","891.94","1910.74","1 through 10","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","1829.79","1561.50","2617.12","88","830.77","1456.14","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1359.46","1201.30","1689.00","61","934.5","1466.23","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1718.92","1718.92","1718.92","1 through 10","934.5","1466.23","percent of total billed charges",""
"KNEE WEDGE SZ 7 10MM FEMORAL DISTAL LEGION","SUP-ITM-10199456","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","1910.74","1019.06","2344.84","74","934.5","1466.23","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","464.71","67.87","1012.10","221","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.78","58.3","","293.04","293.04","293.04","11","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","983.89","983.89","983.89","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","812.58","58","","677.18","677.18","677.18","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","875.63","62.5","","46.58","46.58","46.58","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","747.15","747.15","747.15","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.74","44.45","","1141.67","481.21","1141.67","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.74","44.45","","76.54","76.54","76.54","1 through 10","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","273.64","94.28","1367.51","138","622.74","1091.52","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","720.78","230.14","2010.94","427","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","830.79","59.3","","344.45","344.45","344.45","1 through 10","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","1120.13","1120.13","1120.13","1 through 10","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE TIBIAL 2 15MM SIZE 1 GENESIS LEGION II SCREW ON FULL STEPPED HEMI","SUP-ITM-10146039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","456.17","105.33","1284.66","242","700.5","1099.08","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","both","","","42.68","32.01","AETNA [1001]","HB CH AETNA HMO / PPO","24.88","58.3","","25.29","25.29","25.29","1 through 10","18.97","256.21","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","both","","","42.68","32.01","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","30.77","72.1","","33.46","33.46","33.46","1 through 10","18.97","256.21","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","both","","","42.68","32.01","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","27.06","63.4","","29.44","29.44","33.46","1 through 10","18.97","256.21","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","42.68","32.01","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24.63","57.7","","26.90","24.64","48.98","1 through 10","21.34","208.64","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","42.68","32.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.48","78.45","","34.30","34.30","34.30","1 through 10","21.34","208.64","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0300","RC","","","","inpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","33.60","56","","33.99","33.99","33.99","1 through 10","33.6","42.36","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","84","5.92","57","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","30.74","30.74","30.74","1 through 10","5.92","57","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","32.89","32.89","32.89","1 through 10","5.92","57","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","TRICARE [160005]","HB NWH TRICARE","57.00","95","","7.28","7.28","7.28","1 through 10","5.92","57","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","26.42","26.42","26.42","1 through 10","5.92","57","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","71","6.23","47.07","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","75","6.23","47.07","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0300","RC","","","","inpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","74.84","70.6","","79.19","46.93","79.19","1 through 10","59.36","74.84","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","30","11.34","100.7","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.12","44.45","","75.83","75.83","75.83","1 through 10","11.34","100.7","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","213.84","40","11.01","83.16","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","103.00","103.00","103.00","1 through 10","11.01","83.16","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","46.93","79.19","14","11.01","83.16","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","191.07","72.1","","194.53","194.53","194.53","1 through 10","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","168.01","63.4","","171.05","171.05","171.05","11","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","153.70","58","","130.29","130.29","390.87","1 through 10","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","153.70","58","","153.25","148.87","153.25","16","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","161.39","60.9","","160.99","160.22","160.99","1 through 10","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","165.63","62.5","","165.12","165.12","165.12","31","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","265.00","198.75","WELLPOINT [1015]","HB CH WELLPOINT","206.46","77.91","","203.20","203.20","203.20","1 through 10","140.45","252.02","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","265.00","198.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","152.91","57.7","","155.57","155.57","297.47","31","117.79","207.89","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","265.00","198.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","160.33","60.5","","171.05","157.12","312.44","17","117.79","207.89","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","265.00","198.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","160.33","60.5","","157.12","157.12","157.12","1 through 10","117.79","207.89","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","both","","","171.00","128.25","AETNA [1001]","HB CH AETNA HMO / PPO","99.69","58.3","","94.12","94.12","94.12","1 through 10","19.31","162.45","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","outpatient","","","171.00","128.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.40","59.3","","291.84","97.28","291.84","1 through 10","20.24","134.15","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","outpatient","","","171.00","128.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.15","78.45","","127.62","127.62","127.62","1 through 10","20.24","134.15","percent of total billed charges",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","both","","","1716.00","1287.00","AETNA [1001]","HB CH AETNA HMO / PPO","1000.43","58.3","","7293.89","7293.89","7293.89","1 through 10","736.16","1336.94","percent of total billed charges",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","736.16","1336.94","per diem",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","736.16","1336.94","per diem",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","both","","","1716.00","1287.00","WELLPOINT [1015]","HB CH WELLPOINT","1336.94","77.91","","2773.92","2773.92","2773.92","1 through 10","736.16","1336.94","percent of total billed charges",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","outpatient","","","1716.00","1287.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","842.04","49.07","","7589.12","7589.12","7589.12","1 through 10","686.4","1346.2","percent of total billed charges",""
"Lap Abd/Periton/Omenum Bx","PX-75000285","CDM","49321","CPT","0750","RC","","","","outpatient","","","1716.00","1287.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","859.72","50.1","","7599.63","7441.96","7599.63","1 through 10","686.4","1346.2","percent of total billed charges",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","51198.14","38398.60","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15095.58","","Case rate ($14,655.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,055.59, add-ons for qualifying new technology services are included. If operating cost exceeds $60,197.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,061.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,535.91. The transfer operating threshold is the transfer adjustment factor * $15,055.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.99. The transfer capital threshold is the transfer adjustment factor * $1,119.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18785.41","18785.41","18785.41","1 through 10","14362.78","16399.9176","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","51198.14","38398.60","MEDICARE [2001]","HB NWH MEDICARE","14655.90","","Case rate ($14,655.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,055.59, add-ons for qualifying new technology services are included. If operating cost exceeds $60,197.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,061.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,535.91. The transfer operating threshold is the transfer adjustment factor * $15,055.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.99. The transfer capital threshold is the transfer adjustment factor * $1,119.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15856.50","15828.04","15856.50","22","14362.78","16399.9176","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","51198.14","38398.60","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14362.78","","Case rate ($14,655.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,055.59, add-ons for qualifying new technology services are included. If operating cost exceeds $60,197.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,061.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,535.91. The transfer operating threshold is the transfer adjustment factor * $15,055.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.99. The transfer capital threshold is the transfer adjustment factor * $1,119.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14167.85","14156.88","14171.07","1 through 10","14362.78","16399.9176","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","51198.14","38398.60","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14362.78","","Case rate ($14,655.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,055.59, add-ons for qualifying new technology services are included. If operating cost exceeds $60,197.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,061.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,535.91. The transfer operating threshold is the transfer adjustment factor * $15,055.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.99. The transfer capital threshold is the transfer adjustment factor * $1,119.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14159.77","14159.77","14159.77","1 through 10","14362.78","16399.9176","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","64584.72","48438.54","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","20675.58","","Case rate ($20,675.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,239.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,381.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,521.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,095.59. The transfer operating threshold is the transfer adjustment factor * $21,239.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.01. The transfer capital threshold is the transfer adjustment factor * $1,580.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14305.45","14305.45","14305.45","1 through 10","20262.07","23501.2085","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","64584.72","48438.54","MEDICARE [2001]","HB NWH MEDICARE","20675.58","","Case rate ($20,675.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,239.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,381.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,521.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,095.59. The transfer operating threshold is the transfer adjustment factor * $21,239.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.01. The transfer capital threshold is the transfer adjustment factor * $1,580.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22722.50","22681.73","22722.50","1 through 10","20262.07","23501.2085","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","64584.72","48438.54","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","20262.07","","Case rate ($20,675.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,239.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,381.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,521.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,095.59. The transfer operating threshold is the transfer adjustment factor * $21,239.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.01. The transfer capital threshold is the transfer adjustment factor * $1,580.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11235.12","11235.12","11235.12","1 through 10","20262.07","23501.2085","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","64584.72","48438.54","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20262.07","","Case rate ($20,675.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,239.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,381.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,521.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,095.59. The transfer operating threshold is the transfer adjustment factor * $21,239.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.01. The transfer capital threshold is the transfer adjustment factor * $1,580.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20257.12","20257.12","20257.12","1 through 10","20262.07","23501.2085","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","48447.95","36335.96","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","14698.64","14698.64","14698.64","1 through 10","11596.52","14019.94","case rate",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","48447.95","36335.96","MEDICARE [2001]","HB NWH MEDICARE","11833.18","","Case rate ($11,833.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,155.90, add-ons for qualifying new technology services are included. If operating cost exceeds $57,298.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,846.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,928.91. The transfer operating threshold is the transfer adjustment factor * $12,155.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $904.28. The transfer capital threshold is the transfer adjustment factor * $904.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12575.40","6928.65","12598.01","1 through 10","11596.52","14019.94","other","Inpatient Replacement Plans DRG"
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","both","","","1625.00","1218.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","10712.94","10712.94","10712.94","1 through 10","697.13","9004.88","other","Multiple Surgery"
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","both","","","1625.00","1218.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","697.13","9004.88","per diem",""
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","outpatient","","","1625.00","1218.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","7431.45","7431.45","7431.45","1 through 10","812.5","7178","other","ASC "
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","outpatient","","","1625.00","1218.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7599.63","7599.63","7599.63","1 through 10","812.5","7178","other","ASC "
"Laryngoscopy","PX-76000766","CDM","31525","CPT","0761","RC","","","","outpatient","","","4089.00","3066.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1108.63","1108.63","1108.63","1 through 10","1232.36","3207.82","other","ASC "
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","outpatient","","","5095.00","3821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3021.34","59.3","","17970.27","17970.27","17970.27","1 through 10","2038","3997.03","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord","PX-76000769","CDM","31570","CPT","0761","RC","","","","outpatient","","","4310.00","3232.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5796.49","5796.49","5796.49","1 through 10","2155","4472.66","other","Multiple Surgery"
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","AETNA [1001]","HB CH AETNA HMO / PPO","3024.67","58.3","","464.71","67.87","1012.10","221","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3024.67","58.3","","293.04","293.04","293.04","11","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2749.70","53","","983.89","983.89","983.89","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3009.11","58","","677.18","677.18","677.18","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3242.58","62.5","","46.58","46.58","46.58","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3787.33","73","","747.15","747.15","747.15","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.12","44.45","","1141.67","481.21","1141.67","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.12","44.45","","76.54","76.54","76.54","1 through 10","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","WELLPOINT [1015]","HB CH WELLPOINT","4042.06","77.91","","273.64","94.28","1367.51","138","2306.12","4042.06","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","3076.56","59.3","","720.78","230.14","2010.94","427","2594.06","4070.08","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3076.56","59.3","","344.45","344.45","344.45","1 through 10","2594.06","4070.08","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4070.08","78.45","","1120.13","1120.13","1120.13","1 through 10","2594.06","4070.08","percent of total billed charges",""
"LATERAL PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LEFT","SUP-ITM-10144607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4070.08","78.45","","456.17","105.33","1284.66","242","2594.06","4070.08","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","141.00","105.75","AETNA [1001]","HB CH AETNA HMO / PPO","82.20","58.3","","77.68","77.68","77.68","1 through 10","11.87","133.95","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","141.00","105.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.61","59.3","","80.28","80.28","80.28","1 through 10","12.49","110.61","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","141.00","105.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.61","78.45","","105.33","62.42","105.33","1 through 10","12.49","110.61","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","6038.55","6038.55","6038.55","1 through 10","1590","2337.3","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","3120.45","3120.45","3120.45","1 through 10","1333.5","2353.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","5458.48","2426.07","8187.72","1 through 10","1333.5","2353.5","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4161.25","3120.94","AETNA [1001]","HB CH AETNA HMO / PPO","2426.01","58.3","","6038.55","6038.55","6038.55","1 through 10","2205.46","3242.03","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4161.25","3120.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2467.62","59.3","","3120.45","3120.45","3120.45","1 through 10","1849.68","3264.5","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4161.25","3120.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3264.50","78.45","","5458.48","2426.07","8187.72","1 through 10","1849.68","3264.5","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","5919.46","4439.59","AETNA [1001]","HB CH AETNA HMO / PPO","3451.05","58.3","","6038.55","6038.55","6038.55","1 through 10","3137.31","4611.85","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5919.46","4439.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","3510.24","59.3","","3120.45","3120.45","3120.45","1 through 10","2631.2","4643.82","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5919.46","4439.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4643.82","78.45","","5458.48","2426.07","8187.72","1 through 10","2631.2","4643.82","percent of total billed charges",""
"LEAD PACING CAPSUREFIX 6.2FR 45CM NOVUS MRI SILICONE STEROID ELUTING TRANSVENOUS ATRIUM RV ACTIVE SCREW IS1 BI","SUP-ITM-10010992","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","653.78","59.3","","509.82","509.82","509.82","1 through 10","551.25","864.91","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1445.16","1083.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","856.98","59.3","","509.82","509.82","509.82","1 through 10","722.58","1133.73","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","AETNA [1001]","HB CH AETNA HMO / PPO","3935.25","58.3","","6038.55","6038.55","6038.55","1 through 10","3577.5","5258.93","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4002.75","59.3","","3120.45","3120.45","3120.45","1 through 10","3000.38","5295.38","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5295.38","78.45","","5458.48","2426.07","8187.72","1 through 10","3000.38","5295.38","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","6038.55","6038.55","6038.55","1 through 10","2067","3038.49","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","3120.45","3120.45","3120.45","1 through 10","1733.55","3059.55","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","5458.48","2426.07","8187.72","1 through 10","1733.55","3059.55","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","both","","","146.00","109.50","AETNA [1001]","HB CH AETNA HMO / PPO","85.12","58.3","","216.59","216.59","216.59","1 through 10","15.75","138.7","percent of total billed charges",""
"Leishmania Antibody","PX-30000965","CDM","86717","CPT","0302","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","57.83","57.83","57.83","1 through 10","12.01","99.75","percent of total billed charges",""
"Leptospira Antibody","PX-30000967","CDM","86720","CPT","0302","RC","","","","both","","","99.00","74.25","AETNA [1001]","HB CH AETNA HMO / PPO","57.72","58.3","","54.43","54.43","54.43","1 through 10","15.88","94.05","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","14.75","122.55","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","1 through 10","4.18","32.3","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","19.34","1 through 10","4.4","26.95","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","15.03","25.37","1 through 10","4.4","26.95","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0250","RC","","","","outpatient","","","0.01","0.01","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","49.07","","0.45","0.45","0.45","1 through 10","0.01","0.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0250","RC","","","","outpatient","","","0.01","0.01","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","0.01","50.1","","0.36","0.36","0.36","20","0.01","0.01","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","0.01","0.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","0.01","73","","3.93","3.93","3.93","1 through 10","0.01","0.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","0.01","0.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.01","52.2","","0.10","0.09","0.13","61","0.01","0.01","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","0.01","0.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","0.01","78.45","","0.06","0.06","0.06","1 through 10","0.01","0.01","percent of total billed charges",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","68334.64","51250.98","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","33580.42","","Case rate ($32,602.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,491.47, add-ons for qualifying new technology services are included. If operating cost exceeds $78,633.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,433.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $30,110.92. The transfer operating threshold is the transfer adjustment factor * $33,491.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,491.44. The transfer capital threshold is the transfer adjustment factor * $2,491.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22096.60","22096.60","22096.60","1 through 10","31950.3","37799.7136","other","Inpatient DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","68334.64","51250.98","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","32602.35","","Case rate ($32,602.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,491.47, add-ons for qualifying new technology services are included. If operating cost exceeds $78,633.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,433.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $30,110.92. The transfer operating threshold is the transfer adjustment factor * $33,491.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,491.44. The transfer capital threshold is the transfer adjustment factor * $2,491.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26592.12","26592.12","32962.34","1 through 10","31950.3","37799.7136","other","Inpatient Replacement Plans DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","68334.64","51250.98","MEDICARE [2001]","HB NWH MEDICARE","32602.35","","Case rate ($32,602.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,491.47, add-ons for qualifying new technology services are included. If operating cost exceeds $78,633.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,433.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $30,110.92. The transfer operating threshold is the transfer adjustment factor * $33,491.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,491.44. The transfer capital threshold is the transfer adjustment factor * $2,491.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35366.73","29475.34","36481.64","1 through 10","31950.3","37799.7136","other","Inpatient Replacement Plans DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","68334.64","51250.98","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","31950.30","","Case rate ($32,602.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,491.47, add-ons for qualifying new technology services are included. If operating cost exceeds $78,633.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,433.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $30,110.92. The transfer operating threshold is the transfer adjustment factor * $33,491.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,491.44. The transfer capital threshold is the transfer adjustment factor * $2,491.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26291.23","26291.23","26291.23","1 through 10","31950.3","37799.7136","other","Inpatient DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","68334.64","51250.98","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","31950.30","","Case rate ($32,602.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,491.47, add-ons for qualifying new technology services are included. If operating cost exceeds $78,633.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,433.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $30,110.92. The transfer operating threshold is the transfer adjustment factor * $33,491.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,491.44. The transfer capital threshold is the transfer adjustment factor * $2,491.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32618.86","32618.86","32618.86","1 through 10","31950.3","37799.7136","other","Inpatient DRG"
"Lipase","PX-30000551","CDM","83690","CPT","0300","RC","","","","inpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.36","56","","43.68","43.68","43.68","1 through 10","45.36","57.19","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0300","RC","","","","inpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.19","70.6","","60.74","35.99","60.74","1 through 10","45.36","57.19","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","AETNA [1001]","HB CH AETNA HMO / PPO","47.22","58.3","","44.79","44.79","44.79","107","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.22","58.3","","44.79","44.79","44.79","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.93","53","","23.85","23.85","23.85","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.13","73","","66.30","66.30","66.30","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","TRICARE [160005]","HB NWH TRICARE","76.95","95","","8.30","7.89","8.30","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","60.74","35.99","60.74","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","35.99","35.99","35.99","1 through 10","6.75","76.95","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","46.29","46.29","138.87","141","7.1","63.54","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","79.00","79.00","79.00","1 through 10","7.1","63.54","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","60.74","35.99","60.74","62","7.1","63.54","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0300","RC","","","","inpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.95","70.6","","81.49","81.49","81.49","1 through 10","61.04","76.95","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","AETNA [1001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","2024","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","CHAMPVA [160001]","HB NWH TRICARE","103.55","95","","16.13","16.13","16.13","1 through 10","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","79.57","73","","77.38","77.38","77.38","1 through 10","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","1 through 10","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","79.57","73","","60.10","13.12","106.00","18","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","TRICARE [160005]","HB NWH TRICARE","103.55","95","","16.13","15.32","16.13","36","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","103.55","95","","13.39","13.39","13.39","1 through 10","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.45","44.45","","81.49","48.29","81.49","77","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.45","44.45","","48.29","48.29","81.49","1 through 10","13.12","103.55","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","1927","13.81","85.51","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","64.64","59.3","","60.63","60.63","62.12","1 through 10","13.81","85.51","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","81.49","78.10","81.49","1 through 10","13.81","85.51","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","81.49","48.29","81.49","1751","13.81","85.51","percent of total billed charges",""
"Lipoprotein Blood by Nmr","PX-30000558","CDM","83704","CPT","0301","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB CH AETNA HMO / PPO","214.54","58.3","","202.99","202.99","202.99","1 through 10","33.51","349.6","percent of total billed charges",""
"Lipoprotein Blood by Nmr","PX-30000558","CDM","83704","CPT","0301","RC","","","","outpatient","","","368.00","276.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","218.22","59.3","","209.79","209.79","209.79","1 through 10","32.54","288.7","percent of total billed charges",""
"Lipoprotein Blood by Nmr","PX-30000558","CDM","83704","CPT","0301","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","288.70","78.45","","275.23","275.23","275.23","1 through 10","32.54","288.7","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","76.00","57.00","AETNA [1001]","HB CH AETNA HMO / PPO","44.31","58.3","","41.96","41.96","41.96","17","6.48","72.2","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","76.00","57.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.07","59.3","","43.36","37.00","43.36","1 through 10","6.82","59.62","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","59.62","78.45","","56.89","56.89","56.89","15","6.82","59.62","percent of total billed charges",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","60791.54","45593.65","MEDICARE [2001]","HB NWH MEDICARE","17184.32","","Case rate ($17,184.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,055.08, add-ons for qualifying new technology services are included. If operating cost exceeds $61,197.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,136.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,989.98. The transfer operating threshold is the transfer adjustment factor * $16,055.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,194.34. The transfer capital threshold is the transfer adjustment factor * $1,194.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18830.65","18830.65","18830.65","1 through 10","15316.28","18517.03","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC","497","MS-DRG","","","","","","","","inpatient","","","35922.01","26941.51","MEDICARE [2001]","HB NWH MEDICARE","11510.51","","Case rate ($11,510.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,754.12, add-ons for qualifying new technology services are included. If operating cost exceeds $55,896.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,741.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,710.51. The transfer operating threshold is the transfer adjustment factor * $10,754.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $800.00. The transfer capital threshold is the transfer adjustment factor * $800.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12837.04","12837.04","12837.04","1 through 10","10259.25","12403.2","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC","498","MS-DRG","","","","","","","","inpatient","","","69289.81","51967.36","MEDICARE [2001]","HB NWH MEDICARE","28738.64","","Case rate ($28,738.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,850.14, add-ons for qualifying new technology services are included. If operating cost exceeds $71,992.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,939.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $26,741.26. The transfer operating threshold is the transfer adjustment factor * $26,850.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,997.39. The transfer capital threshold is the transfer adjustment factor * $1,997.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24141.40","24141.40","24141.40","1 through 10","24968.7361","28738.64","other","Inpatient DRG"
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","464.71","67.87","1012.10","221","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","293.04","293.04","293.04","11","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","983.89","983.89","983.89","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.00","58","","677.18","677.18","677.18","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.50","62.5","","46.58","46.58","46.58","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","747.15","747.15","747.15","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","1141.67","481.21","1141.67","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","76.54","76.54","76.54","1 through 10","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","273.64","94.28","1367.51","138","400.05","701.19","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","720.78","230.14","2010.94","427","450","706.05","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.70","59.3","","344.45","344.45","344.45","1 through 10","450","706.05","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1120.13","1120.13","1120.13","1 through 10","450","706.05","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","456.17","105.33","1284.66","242","450","706.05","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","AETNA [1001]","HB CH AETNA HMO / PPO","493.22","58.3","","466.64","466.64","466.64","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","130.06","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","129.95","129.95","129.95","14","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","18","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","609.97","72.1","","620.54","620.54","620.54","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","536.36","63.4","","545.65","545.65","620.54","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","212","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","26","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.67","35.54","","374.96","374.96","374.96","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","123.77","40","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","536.36","63.4","","545.65","545.65","545.65","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","WELLPOINT [1015]","HB CH WELLPOINT","659.12","77.91","","648.19","648.19","648.19","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","488.14","57.7","","496.27","496.27","948.92","55","243.42","511.83","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","511.83","60.5","","520.96","520.96","545.65","12","243.42","511.83","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","300.67","35.54","","286.65","286.65","374.96","16","243.42","511.83","percent of total billed charges",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","64848.76","48636.57","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","21972.58","","Case rate ($21,972.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,571.81, add-ons for qualifying new technology services are included. If operating cost exceeds $67,714.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,621.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,293.46. The transfer operating threshold is the transfer adjustment factor * $22,571.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.12. The transfer capital threshold is the transfer adjustment factor * $1,679.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22051.81","22051.81","22051.81","1 through 10","21533.13","23743.489","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","64848.76","48636.57","MEDICARE [2001]","HB NWH MEDICARE","21972.58","","Case rate ($21,972.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,571.81, add-ons for qualifying new technology services are included. If operating cost exceeds $67,714.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,621.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,293.46. The transfer operating threshold is the transfer adjustment factor * $22,571.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.12. The transfer capital threshold is the transfer adjustment factor * $1,679.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19676.22","19676.22","22915.55","1 through 10","21533.13","23743.489","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","64848.76","48636.57","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","21533.13","","Case rate ($21,972.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,571.81, add-ons for qualifying new technology services are included. If operating cost exceeds $67,714.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,621.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,293.46. The transfer operating threshold is the transfer adjustment factor * $22,571.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.12. The transfer capital threshold is the transfer adjustment factor * $1,679.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","97.81","97.81","97.81","1 through 10","21533.13","23743.489","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","65923.38","49442.53","MEDICARE [2001]","HB NWH MEDICARE","31810.48","","Case rate ($31,810.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,678, add-ons for qualifying new technology services are included. If operating cost exceeds $77,820.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,372.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,379.55. The transfer operating threshold is the transfer adjustment factor * $32,677.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,430.92. The transfer capital threshold is the transfer adjustment factor * $2,430.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33893.27","33893.27","33893.27","1 through 10","31174.27","35117.8168","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","65923.38","49442.53","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","31174.27","","Case rate ($31,810.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,678, add-ons for qualifying new technology services are included. If operating cost exceeds $77,820.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,372.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,379.55. The transfer operating threshold is the transfer adjustment factor * $32,677.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,430.92. The transfer capital threshold is the transfer adjustment factor * $2,430.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26613.50","26613.50","26613.50","1 through 10","31174.27","35117.8168","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","59500.34","44625.25","MEDICARE [2001]","HB NWH MEDICARE","19114.33","","Case rate ($19,114.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,858.26, add-ons for qualifying new technology services are included. If operating cost exceeds $63,000.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,270.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,785.85. The transfer operating threshold is the transfer adjustment factor * $17,858.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,328.48. The transfer capital threshold is the transfer adjustment factor * $1,328.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17994.58","17994.58","18026.93","1 through 10","17036.49","19114.33","other","Inpatient DRG"
"Lower Vascular Procedures,MAJOR","181","DRG","","","","","","","","inpatient","","","121004.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","85079.89","","Standard inlier is a Case rate ($85,079.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $92,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,076.73) for the length of stay and the standard reimbursement.","81212.61","81212.61","81212.61","1 through 10","15555.6","85079.89","case rate",""
"Lower Vascular Procedures,MINOR","181","DRG","","","","","","","","inpatient","","","78646.59","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","15555.60","","Case rate ($16,758.70). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,188.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16801.80","16801.80","16801.80","1 through 10","15555.6","85079.89","case rate",""
"Lower Vascular Procedures,MODERATE","181","DRG","","","","","","","","inpatient","","","67132.73","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","54745.75","","Standard inlier is a Case rate ($54,745.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $63,932, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,770.93) for the length of stay and the standard reimbursement.","52257.30","52257.30","52257.30","1 through 10","15555.6","85079.89","case rate",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","both","","","137.08","102.81","AETNA [1001]","HB CH AETNA HMO / PPO","79.92","58.3","","80.02","80.02","80.02","1 through 10","40.84","153.26","percent of total billed charges",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","137.08","102.81","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","79.10","57.7","","170.19","170.19","170.19","1 through 10","60.93","137.08","percent of total billed charges",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","137.08","102.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.54","78.45","","249.61","249.61","249.61","1 through 10","60.93","137.08","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","AETNA [1001]","HB CH AETNA HMO / PPO","2368.44","58.3","","464.71","67.87","1012.10","221","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2368.44","58.3","","293.04","293.04","293.04","11","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2153.13","53","","983.89","983.89","983.89","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2356.25","58","","677.18","677.18","677.18","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2539.06","62.5","","46.58","46.58","46.58","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2965.63","73","","747.15","747.15","747.15","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1805.78","44.45","","1141.67","481.21","1141.67","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1805.78","44.45","","76.54","76.54","76.54","1 through 10","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","WELLPOINT [1015]","HB CH WELLPOINT","3165.09","77.91","","273.64","94.28","1367.51","138","1805.78","3165.09","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2409.06","59.3","","720.78","230.14","2010.94","427","2031.25","3187.03","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2409.06","59.3","","344.45","344.45","344.45","1 through 10","2031.25","3187.03","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3187.03","78.45","","1120.13","1120.13","1120.13","1 through 10","2031.25","3187.03","percent of total billed charges",""
"LUMBAR CAGE 7.0X17 14MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3187.03","78.45","","456.17","105.33","1284.66","242","2031.25","3187.03","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","AETNA [1001]","HB CH AETNA HMO / PPO","4343.35","58.3","","2190.90","412.50","9264.59","16","3311.53","5804.3","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4321.00","58","","1903.20","1903.20","3826.66","1 through 10","3311.53","5804.3","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4656.25","62.5","","2186.25","2186.25","2186.25","32","3311.53","5804.3","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5438.50","73","","5556.60","5556.60","5556.60","1 through 10","3311.53","5804.3","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","WELLPOINT [1015]","HB CH WELLPOINT","5804.30","77.91","","1955.15","885.83","3150.40","26","3311.53","5804.3","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","831.03","253.22","2394.88","18","3725","5844.53","percent of total billed charges",""
"LUMBAR CAGE 8X18 50MM XL COROENT PEEK","SUP-ITM-10026718","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5844.53","78.45","","2481.69","1563.74","8149.28","1 through 10","3725","5844.53","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1159.00","869.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","515.18","902.98","per diem",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1159.00","869.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","988.81","968.26","988.81","1 through 10","579.5","1873.9","other","ASC "
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1159.00","869.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","969.63","990.18","1 through 10","579.5","1873.9","other","ASC "
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1159.00","869.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","579.5","1873.9","other","Multiple Surgery"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1159.00","869.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1425.17","1425.17","1425.17","1 through 10","579.5","1873.9","other","Multiple Surgery"
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","AETNA [1001]","HB CH AETNA HMO / PPO","4314.20","58.3","","2190.90","412.50","9264.59","16","3289.3","5765.34","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4292.00","58","","1903.20","1903.20","3826.66","1 through 10","3289.3","5765.34","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4625.00","62.5","","2186.25","2186.25","2186.25","32","3289.3","5765.34","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5402.00","73","","5556.60","5556.60","5556.60","1 through 10","3289.3","5765.34","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","WELLPOINT [1015]","HB CH WELLPOINT","5765.34","77.91","","1955.15","885.83","3150.40","26","3289.3","5765.34","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4388.20","59.3","","831.03","253.22","2394.88","18","3700","5805.3","percent of total billed charges",""
"LUMBAR SPACER 32X23 12MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5805.30","78.45","","2481.69","1563.74","8149.28","1 through 10","3700","5805.3","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","2190.90","412.50","9264.59","16","1955.8","3428.04","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","1903.20","1903.20","3826.66","1 through 10","1955.8","3428.04","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","2186.25","2186.25","2186.25","32","1955.8","3428.04","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","5556.60","5556.60","5556.60","1 through 10","1955.8","3428.04","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","1955.15","885.83","3150.40","26","1955.8","3428.04","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","831.03","253.22","2394.88","18","2200","3451.8","percent of total billed charges",""
"LUMBAR SPACER 9X28MM 4DEG PLATE COROENT MAS ALPHA INTERBODY FUSION","SUP-ITM-10115287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","2481.69","1563.74","8149.28","1 through 10","2200","3451.8","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","218.00","163.50","AETNA [1001]","HB CH AETNA HMO / PPO","127.09","58.3","","120.20","120.20","120.20","129","18.15","207.1","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","218.00","163.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","159.14","73","","34.16","34.16","34.16","1 through 10","18.15","207.1","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","218.00","163.50","TRICARE [160005]","HB NWH TRICARE","207.10","95","","22.32","21.20","22.32","1 through 10","18.15","207.1","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.90","44.45","","162.99","96.59","162.99","1 through 10","18.15","207.1","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","218.00","163.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","124.23","147.22","127","19.09","171.02","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.02","78.45","","162.99","96.59","162.99","109","19.09","171.02","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","AETNA [1001]","HB CH AETNA HMO / PPO","98.53","58.3","","92.99","92.99","92.99","190","16.69","160.55","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","123.37","73","","192.21","192.21","192.21","1 through 10","16.69","160.55","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","TRICARE [160005]","HB NWH TRICARE","160.55","95","","20.52","20.52","20.52","1 through 10","16.69","160.55","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.12","44.45","","126.09","126.09","126.09","1 through 10","16.69","160.55","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.12","44.45","","74.72","74.72","74.72","1 through 10","16.69","160.55","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","169.00","126.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.22","59.3","","96.11","96.11","192.21","175","14.72","132.58","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","132.58","78.45","","126.09","74.72","126.09","130","14.72","132.58","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","100.36","100.36","100.36","22","15.18","172.9","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","182.00","136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.93","59.3","","103.72","103.72","207.44","21","15.98","142.78","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","136.08","80.64","136.08","30","15.98","142.78","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","outpatient","","","576.00","432.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","341.57","59.3","","328.16","328.16","328.16","1 through 10","50.56","451.87","percent of total billed charges",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","28485.88","21364.41","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15541.05","","Case rate ($15,541.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,519.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,662.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,460.92. The transfer operating threshold is the transfer adjustment factor * $14,519.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.13. The transfer capital threshold is the transfer adjustment factor * $1,080.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14752.29","14752.29","14752.29","1 through 10","13851.64","15541.05","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","28485.88","21364.41","MEDICARE [2001]","HB NWH MEDICARE","15541.05","","Case rate ($15,541.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,519.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,662.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,460.92. The transfer operating threshold is the transfer adjustment factor * $14,519.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.13. The transfer capital threshold is the transfer adjustment factor * $1,080.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14965.26","14965.06","14992.16","1 through 10","13851.64","15541.05","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","28485.88","21364.41","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13851.64","","Case rate ($14,134.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,519.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,662.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,054.20. The transfer operating threshold is the transfer adjustment factor * $14,519.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.13. The transfer capital threshold is the transfer adjustment factor * $1,080.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6863.91","6863.91","6863.91","1 through 10","13851.64","15541.05","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","42458.96","31844.22","MEDICARE [2001]","HB NWH MEDICARE","28026.93","","Case rate ($28,026.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,791.27, add-ons for qualifying new technology services are included. If operating cost exceeds $73,933.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,083.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $25,885.14. The transfer operating threshold is the transfer adjustment factor * $28,791.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,141.79. The transfer capital threshold is the transfer adjustment factor * $2,141.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30436.36","30436.36","30491.08","1 through 10","27466.39","31536.021","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","42458.96","31844.22","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","27466.39","","Case rate ($28,026.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,791.27, add-ons for qualifying new technology services are included. If operating cost exceeds $73,933.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,083.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $25,885.14. The transfer operating threshold is the transfer adjustment factor * $28,791.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,141.79. The transfer capital threshold is the transfer adjustment factor * $2,141.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27197.05","27197.05","27197.05","1 through 10","27466.39","31536.021","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","40172.09","30129.07","MEDICARE [2001]","HB NWH MEDICARE","43675.73","","Case rate ($43,675.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,805.66, add-ons for qualifying new technology services are included. If operating cost exceeds $85,947.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,977.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $40,640.19. The transfer operating threshold is the transfer adjustment factor * $40,805.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,035.54. The transfer capital threshold is the transfer adjustment factor * $3,035.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44661.94","44661.94","44661.94","1 through 10","38927.91","46275.5755","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","15907.59","11930.69","MEDICARE [2001]","HB NWH MEDICARE","9625.26","","Case rate ($9,625.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,992.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,135.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,610.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,956.30. The transfer operating threshold is the transfer adjustment factor * $8,992.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.97. The transfer capital threshold is the transfer adjustment factor * $668.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10039.51","10039.51","10039.51","1 through 10","8578.94","10371.76","other","Inpatient DRG"
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","31703.09","","MASSHEALTH [3001]","HB NWH MEDICAID","40359.79","","Case rate ($43,481.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $85,911.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","43593.12","43593.12","43593.12","1 through 10","2821","204884.82","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","53487.54","","MASSHEALTH [3001]","HB NWH MEDICAID","21667.26","","Case rate ($23,343.05). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $65,773.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17539.78","17539.78","17539.78","1 through 10","2821","204884.82","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","53487.54","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","18257.12","","Fee schedule rate ($18,257.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18256.99","18256.99","18256.99","1 through 10","2821","204884.82","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MINOR","691","DRG","","","","","","","","inpatient","","","25075.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22252.23","","Standard inlier is a Case rate ($22,252.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,158.61) for the length of stay and the standard reimbursement.","22252.23","22252.23","22252.23","1 through 10","2821","204884.82","case rate",""
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","AETNA [1001]","HB CH AETNA HMO / PPO","511.87","58.3","","484.22","484.22","484.22","1 through 10","390.27","1456.11","percent of total billed charges",""
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","WELLPOINT [1015]","HB CH WELLPOINT","684.05","77.91","","1526.61","628.63","1526.61","1 through 10","390.27","1456.11","percent of total billed charges",""
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","520.65","59.3","","500.44","500.44","500.44","1 through 10","324.26","926.86","percent of total billed charges",""
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","688.79","78.45","","656.56","656.56","656.56","1 through 10","324.26","926.86","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Cptr Each Multiprb","PX-31000496","CDM","88374","CPT","0310","RC","","","","both","","","979.00","734.25","AETNA [1001]","HB CH AETNA HMO / PPO","570.76","58.3","","4318.27","4318.27","4318.27","1 through 10","193.33","768.52","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Cptr Each Multiprb","PX-31000496","CDM","88374","CPT","0310","RC","","","","outpatient","","","979.00","734.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","768.03","78.45","","731.90","731.90","731.90","1 through 10","204.8","768.03","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","1296.16","216.03","1296.16","1 through 10","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","67.83","305.25","24","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","66.48","66.48","199.43","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.42","186.42","186.42","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","WELLPOINT [1015]","HB CH WELLPOINT","305.41","77.91","","300.08","294.82","300.08","11","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","217.93","2520.38","53","196","489.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","173.58","292.91","47","196","489.19","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0300","RC","","","","inpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.28","56","","35.75","33.73","35.75","1 through 10","35.28","44.48","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0300","RC","","","","inpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","44.48","70.6","","46.90","27.79","46.90","1 through 10","35.28","44.48","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","315","6.57","59.85","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","TRICARE [160005]","HB NWH TRICARE","59.85","95","","8.07","7.67","8.07","1 through 10","6.57","59.85","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","44.74","27.79","46.90","28","6.57","59.85","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","35.75","35.75","107.25","436","6.9","49.42","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","61.00","61.00","61.00","1 through 10","6.9","49.42","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","27.79","46.90","252","6.9","49.42","percent of total billed charges",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","87240.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","98615.56","","Standard inlier is a Case rate ($98,615.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $105,827, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,998.06) for the length of stay and the standard reimbursement.","98615.56","98615.56","98615.56","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","87240.06","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29445.8856","","Fee schedule rate ($39,855.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29445.8856","79690.32","79690.32","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","87240.06","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","36017.8602","","Fee schedule rate ($39,855.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36017.8602","79690.32","79690.32","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","87240.06","","MASSHEALTH [3001]","HB NWH MEDICAID","37367.93","","Case rate ($40,258.05). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $82,688.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26251.43","26251.43","26251.43","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MINOR","169","DRG","","","","","","","","inpatient","","","45771.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","69321.07","","Standard inlier is a Case rate ($69,321.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $82,763, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,840.40) for the length of stay and the standard reimbursement.","66171.00","66171.00","66171.00","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MINOR","169","DRG","","","","","","","","inpatient","","","45771.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","74464.65","","Standard inlier is a Case rate ($74,464.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $82,763, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,569.94) for the length of stay and the standard reimbursement.","71079.89","71079.89","71079.89","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","88887.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","70255.09","","Standard inlier is a Case rate ($70,255.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $83,721, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,972.98) for the length of stay and the standard reimbursement.","67062.58","67062.58","67062.58","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","88887.69","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","53793.74","","Fee schedule rate ($53,793.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53793.74","53793.74","53793.74","1 through 10","23660.68","98615.56","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","88887.69","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","31095.20","","Case rate ($33,500.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $75,930.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","33586.32","33586.32","33586.32","1 through 10","23660.68","98615.56","case rate",""
"Major Biliary Tract Procedures,MINOR","261","DRG","","","","","","","","inpatient","","","22321.93","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","28484.4192","","Fee schedule rate ($28,484.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28484.4192","28484.42","28484.42","1 through 10","6229.32","68976.36","case rate",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","62147.78","46610.83","MEDICARE [2001]","HB NWH MEDICARE","26666.70","","Case rate ($26,666.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,914.34, add-ons for qualifying new technology services are included. If operating cost exceeds $70,056.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,795.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $24,813.32. The transfer operating threshold is the transfer adjustment factor * $24,914.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,853.38. The transfer capital threshold is the transfer adjustment factor * $1,853.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15244.99","15244.99","15244.99","1 through 10","23767.87","27907.7469","other","Inpatient DRG"
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","190018.26","","MASSHEALTH [3001]","HB NWH MEDICAID","27342.53","","Case rate ($29,457.26). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $71,887.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38748.94","38748.94","38748.94","1 through 10","24310.935","106605.11","case rate",""
"Major Chest And Respiratory Trauma,EXTREME","135","DRG","","","","","","","","inpatient","","","65062.28","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","51260.31","","Fee schedule rate ($51,260.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","51260.31","51260.31","51260.31","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","37964.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27777.95","","Standard inlier is a Case rate ($27,777.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,145, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,943.19) for the length of stay and the standard reimbursement.","27777.94","27777.94","27777.94","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","37964.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29839.06","","Standard inlier is a Case rate ($29,839.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,145, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,235.53) for the length of stay and the standard reimbursement.","3295.05","3295.05","3295.05","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","37964.65","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","28054.43","","Fee schedule rate ($28,054.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26972.50","26972.50","26972.50","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MINOR","135","DRG","","","","","","","","inpatient","","","24049.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19097.18","","Fee schedule rate ($19,097.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19097.18","19097.18","19097.18","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","26461.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27777.95","","Fee schedule rate ($27,777.95). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,213.47) multiplied by length of stay and the outlier percent (100%).","19364.39","19364.39","19364.39","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","26461.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29839.06","","Fee schedule rate ($29,839.06). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,452.56) multiplied by length of stay and the outlier percent (100%).","19855.71","19855.71","19855.71","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","26461.96","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10955.2452","","Fee schedule rate ($15,023.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10955.2452","14444.98","14444.98","1 through 10","5606.73","72903.68","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","26461.96","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13429.36","","Fee schedule rate ($13,429.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9345.78","9345.78","9345.78","1 through 10","5606.73","72903.68","case rate",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","46268.52","34701.39","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","22523.78","","Case rate ($21,867.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,464.12, add-ons for qualifying new technology services are included. If operating cost exceeds $67,606.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,613.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,196.64. The transfer operating threshold is the transfer adjustment factor * $22,464.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.11. The transfer capital threshold is the transfer adjustment factor * $1,671.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22535.35","22535.35","22535.35","1 through 10","21430.4","24890.613","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","46268.52","34701.39","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","24044.14","","Case rate ($24,044.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,464.12, add-ons for qualifying new technology services are included. If operating cost exceeds $67,606.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,613.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $22,373.03. The transfer operating threshold is the transfer adjustment factor * $22,464.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.11. The transfer capital threshold is the transfer adjustment factor * $1,671.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21892.56","21892.56","21892.56","1 through 10","21430.4","24890.613","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","46268.52","34701.39","MEDICARE [2001]","HB NWH MEDICARE","24044.14","","Case rate ($24,044.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,464.12, add-ons for qualifying new technology services are included. If operating cost exceeds $67,606.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,613.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $22,373.03. The transfer operating threshold is the transfer adjustment factor * $22,464.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.11. The transfer capital threshold is the transfer adjustment factor * $1,671.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24022.66","24022.66","24065.85","25","21430.4","24890.613","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","46268.52","34701.39","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","21430.40","","Case rate ($21,867.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,464.12, add-ons for qualifying new technology services are included. If operating cost exceeds $67,606.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,613.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,196.64. The transfer operating threshold is the transfer adjustment factor * $22,464.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.11. The transfer capital threshold is the transfer adjustment factor * $1,671.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21474.71","21474.71","21474.71","1 through 10","21430.4","24890.613","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","46268.52","34701.39","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","21430.40","","Case rate ($21,867.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,464.12, add-ons for qualifying new technology services are included. If operating cost exceeds $67,606.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,613.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,196.64. The transfer operating threshold is the transfer adjustment factor * $22,464.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.11. The transfer capital threshold is the transfer adjustment factor * $1,671.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21503.00","21503.00","21503.00","1 through 10","21430.4","24890.613","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","80342.33","60256.75","MEDICARE [2001]","HB NWH MEDICARE","42694.54","","Case rate ($42,694.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $39,888.94, add-ons for qualifying new technology services are included. If operating cost exceeds $85,031.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,909.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $39,727.19. The transfer operating threshold is the transfer adjustment factor * $39,888.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,967.35. The transfer capital threshold is the transfer adjustment factor * $2,967.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43990.98","43990.98","43990.98","1 through 10","38053.39","46005.68","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","42131.97","31598.98","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","17082.01","","Case rate ($16,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,036.77, add-ons for qualifying new technology services are included. If operating cost exceeds $62,179.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,209.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,317.12. The transfer operating threshold is the transfer adjustment factor * $17,036.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.37. The transfer capital threshold is the transfer adjustment factor * $1,267.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16690.92","16690.92","16690.92","1 through 10","16252.79","18433.096","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","42131.97","31598.98","MEDICARE [2001]","HB NWH MEDICARE","16584.48","","Case rate ($16,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,036.77, add-ons for qualifying new technology services are included. If operating cost exceeds $62,179.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,209.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,317.12. The transfer operating threshold is the transfer adjustment factor * $17,036.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.37. The transfer capital threshold is the transfer adjustment factor * $1,267.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17822.31","17822.31","17822.31","1 through 10","16252.79","18433.096","other","Inpatient Replacement Plans DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","26461.96","19846.47","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9219.29","","Case rate ($9,219.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,470.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,612.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,646.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,514.76. The transfer operating threshold is the transfer adjustment factor * $9,470.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.53. The transfer capital threshold is the transfer adjustment factor * $704.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9210.72","9210.72","10049.06","1 through 10","9034.9","10402.2391","other","Inpatient Replacement Plans DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","26461.96","19846.47","MEDICARE [2001]","HB NWH MEDICARE","9219.29","","Case rate ($9,219.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,470.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,612.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,646.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,514.76. The transfer operating threshold is the transfer adjustment factor * $9,470.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.53. The transfer capital threshold is the transfer adjustment factor * $704.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10194.00","608.77","10212.46","28","9034.9","10402.2391","other","Inpatient Replacement Plans DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","26461.96","19846.47","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9034.90","","Case rate ($9,219.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,470.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,612.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,646.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,514.76. The transfer operating threshold is the transfer adjustment factor * $9,470.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.53. The transfer capital threshold is the transfer adjustment factor * $704.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9108.28","9108.28","9108.41","1 through 10","9034.9","10402.2391","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","26461.96","19846.47","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9034.90","","Case rate ($9,219.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,470.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,612.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,646.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,514.76. The transfer operating threshold is the transfer adjustment factor * $9,470.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.53. The transfer capital threshold is the transfer adjustment factor * $704.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9140.69","9140.69","9140.69","1 through 10","9034.9","10402.2391","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","38398.40","28798.80","MEDICARE [2001]","HB NWH MEDICARE","14574.15","","Case rate ($14,574.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,616.43, add-ons for qualifying new technology services are included. If operating cost exceeds $58,758.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,954.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,561.21. The transfer operating threshold is the transfer adjustment factor * $13,616.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.93. The transfer capital threshold is the transfer adjustment factor * $1,012.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15176.70","15149.27","15176.70","15","12989.85","15704.42","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","38398.40","28798.80","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12989.85","","Case rate ($13,254.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,616.43, add-ons for qualifying new technology services are included. If operating cost exceeds $58,758.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,954.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,242.01. The transfer operating threshold is the transfer adjustment factor * $13,616.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.93. The transfer capital threshold is the transfer adjustment factor * $1,012.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13536.03","13536.03","13536.03","1 through 10","12989.85","15704.42","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","38398.40","28798.80","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","12989.85","","Case rate ($13,254.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,616.43, add-ons for qualifying new technology services are included. If operating cost exceeds $58,758.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,954.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,242.01. The transfer operating threshold is the transfer adjustment factor * $13,616.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.93. The transfer capital threshold is the transfer adjustment factor * $1,012.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","65.98","65.98","65.98","1 through 10","12989.85","15704.42","other","Inpatient DRG"
"Major Chest Trauma Without Cc/McC","185","MS-DRG","","","","","","","","inpatient","","","22557.73","16918.30","MEDICARE [2001]","HB NWH MEDICARE","7492.36","","Case rate ($7,492.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,000.01, add-ons for qualifying new technology services are included. If operating cost exceeds $52,142.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,462.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,971.63. The transfer operating threshold is the transfer adjustment factor * $7,000.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.73. The transfer capital threshold is the transfer adjustment factor * $520.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1104.59","1104.59","1104.59","1 through 10","6677.9","7690.6753","other","Inpatient DRG"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","","","","inpatient","","","24631.49","18473.62","MEDICARE [2001]","HB NWH MEDICARE","9528.11","","Case rate ($9,528.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,901.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,044.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,604.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,865.89. The transfer operating threshold is the transfer adjustment factor * $8,901.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $662.22. The transfer capital threshold is the transfer adjustment factor * $662.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9712.15","9712.15","9712.15","1 through 10","8492.35","10063.0464","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","30007.35","22505.51","MEDICARE [2001]","HB NWH MEDICARE","15164.77","","Case rate ($15,164.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,168.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,310.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,995.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,110.78. The transfer operating threshold is the transfer adjustment factor * $14,168.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,053.98. The transfer capital threshold is the transfer adjustment factor * $1,053.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15938.77","15938.77","15967.43","1 through 10","13516.27","16340.85","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","30007.35","22505.51","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13516.27","","Case rate ($13,792.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,168.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,310.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,995.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,738.13. The transfer operating threshold is the transfer adjustment factor * $14,168.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,053.98. The transfer capital threshold is the transfer adjustment factor * $1,053.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14247.19","14247.19","14247.19","1 through 10","13516.27","16340.85","other","Inpatient DRG"
"Major Esophageal Disorders,EXTREME","242","DRG","","","","","","","","inpatient","","","64723.28","","MASSHEALTH [3001]","HB NWH MEDICAID","24078.79","","Case rate ($25,941.10). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $68,371.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26007.81","26007.81","26007.81","1 through 10","6442.94","110909.69","case rate",""
"Major Gastrointestinal And Peritoneal Infections,EXTREME","248","DRG","","","","","","","","inpatient","","","294976.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47224.76","","Standard inlier is a Case rate ($47,224.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,748, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,703.36) for the length of stay and the standard reimbursement.","78524.80","78524.80","78524.80","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","32732.53","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25981.12","","Standard inlier is a Case rate ($25,981.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,687.91) for the length of stay and the standard reimbursement.","24801.70","24801.70","25981.12","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","32732.53","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10863.8508","","Fee schedule rate ($122,695.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10863.8508","48513.10","48513.10","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","32732.53","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17783.8173","","Fee schedule rate ($122,695.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17783.8173","48513.10","48513.10","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","32732.53","","MASSHEALTH [3001]","HB NWH MEDICAID","10610.30","","Case rate ($11,430.92). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,860.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11460.31","11460.31","11460.31","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","32732.53","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","23941.20","","Fee schedule rate ($23,941.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11434.65","11434.65","11434.65","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","14781.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10346.4372","","Fee schedule rate ($10,346.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10346.4372","10346.44","10346.44","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","14781.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16937.0514","","Fee schedule rate ($10,346.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16937.0514","10346.44","10346.44","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16464.27","","Standard inlier is a Case rate ($16,464.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,538, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,337.17) for the length of stay and the standard reimbursement.","16464.27","16464.27","16464.27","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17685.91","","Standard inlier is a Case rate ($17,685.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,538, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,510.44) for the length of stay and the standard reimbursement.","16883.67","2046.36","17685.91","13","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10346.4372","","Fee schedule rate ($15,213.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10346.4372","15213.46","15213.46","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16937.0514","","Fee schedule rate ($15,213.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16937.0514","15213.46","15213.46","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","16735.07","","Fee schedule rate ($16,735.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16735.08","16735.08","16735.08","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","MASSHEALTH [3001]","HB NWH MEDICAID","6778.80","","Case rate ($7,303.09). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,733.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7321.87","7321.87","7321.87","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","19051.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","18083.61","","Fee schedule rate ($18,083.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18083.61","18083.61","18083.61","1 through 10","4675.7","192806.22","case rate",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","22869.16","17151.87","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8845.87","","Case rate ($8,845.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,087.10, add-ons for qualifying new technology services are included. If operating cost exceeds $54,229.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,617.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,169.88. The transfer operating threshold is the transfer adjustment factor * $9,087.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.99. The transfer capital threshold is the transfer adjustment factor * $675.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8876.00","8876.00","8876.00","1 through 10","8668.95","10178.7477","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","22869.16","17151.87","MEDICARE [2001]","HB NWH MEDICARE","8845.87","","Case rate ($8,845.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,087.10, add-ons for qualifying new technology services are included. If operating cost exceeds $54,229.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,617.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,169.88. The transfer operating threshold is the transfer adjustment factor * $9,087.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.99. The transfer capital threshold is the transfer adjustment factor * $675.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9823.81","7979.48","9841.47","20","8668.95","10178.7477","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","22869.16","17151.87","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8668.95","","Case rate ($8,845.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,087.10, add-ons for qualifying new technology services are included. If operating cost exceeds $54,229.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,617.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,169.88. The transfer operating threshold is the transfer adjustment factor * $9,087.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.99. The transfer capital threshold is the transfer adjustment factor * $675.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6190.25","42.00","8794.68","1 through 10","8668.95","10178.7477","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","22869.16","17151.87","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8668.95","","Case rate ($8,845.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,087.10, add-ons for qualifying new technology services are included. If operating cost exceeds $54,229.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,617.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,169.88. The transfer operating threshold is the transfer adjustment factor * $9,087.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.99. The transfer capital threshold is the transfer adjustment factor * $675.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8785.23","8776.18","8808.68","1 through 10","8668.95","10178.7477","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","45756.60","34317.45","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15822.87","","Case rate ($15,362.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,780.95, add-ons for qualifying new technology services are included. If operating cost exceeds $60,923.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,115.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,188.06. The transfer operating threshold is the transfer adjustment factor * $15,780.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,173.95. The transfer capital threshold is the transfer adjustment factor * $1,173.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14798.92","14798.92","14798.92","1 through 10","15054.77","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","45756.60","34317.45","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","16890.91","","Case rate ($16,890.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,780.95, add-ons for qualifying new technology services are included. If operating cost exceeds $60,923.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,115.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,716.96. The transfer operating threshold is the transfer adjustment factor * $15,780.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,173.95. The transfer capital threshold is the transfer adjustment factor * $1,173.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15073.82","15073.82","15073.82","1 through 10","15054.77","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","45756.60","34317.45","MEDICARE [2001]","HB NWH MEDICARE","16890.91","","Case rate ($16,890.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,780.95, add-ons for qualifying new technology services are included. If operating cost exceeds $60,923.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,115.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,716.96. The transfer operating threshold is the transfer adjustment factor * $15,780.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,173.95. The transfer capital threshold is the transfer adjustment factor * $1,173.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16683.21","15767.22","16713.20","1 through 10","15054.77","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","45756.60","34317.45","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15054.77","","Case rate ($15,362.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,780.95, add-ons for qualifying new technology services are included. If operating cost exceeds $60,923.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,115.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,188.06. The transfer operating threshold is the transfer adjustment factor * $15,780.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,173.95. The transfer capital threshold is the transfer adjustment factor * $1,173.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5627.10","67.18","14934.82","1 through 10","15054.77","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","45756.60","34317.45","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15054.77","","Case rate ($15,362.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,780.95, add-ons for qualifying new technology services are included. If operating cost exceeds $60,923.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,115.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,188.06. The transfer operating threshold is the transfer adjustment factor * $15,780.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,173.95. The transfer capital threshold is the transfer adjustment factor * $1,173.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25964.42","14904.34","36739.80","1 through 10","15054.77","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","15041.53","11281.15","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9152.34","9152.34","9152.34","1 through 10","6176.11","7466.76","case rate",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","15041.53","11281.15","MEDICARE [2001]","HB NWH MEDICARE","6302.15","","Case rate ($6,302.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,474.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,616.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,423.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,820.54. The transfer operating threshold is the transfer adjustment factor * $6,474.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.60. The transfer capital threshold is the transfer adjustment factor * $481.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6923.34","6923.34","6923.34","1 through 10","6176.11","7466.76","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","15041.53","11281.15","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6176.11","","Case rate ($6,302.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,474.01, add-ons for qualifying new technology services are included. If operating cost exceeds $51,616.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,423.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,820.54. The transfer operating threshold is the transfer adjustment factor * $6,474.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.60. The transfer capital threshold is the transfer adjustment factor * $481.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7087.04","7087.04","7087.04","1 through 10","6176.11","7466.76","other","Inpatient DRG"
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","37250.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26503.17","","Standard inlier is a Case rate ($26,503.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,762.23) for the length of stay and the standard reimbursement.","26503.16","26503.16","26503.16","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","37250.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28469.69","","Standard inlier is a Case rate ($28,469.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,041.15) for the length of stay and the standard reimbursement.","27175.61","27175.61","28469.68","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","37250.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12442.3914","","Fee schedule rate ($33,594.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12442.3914","33594.66","123239.66","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","37250.76","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13064.4473","","Fee schedule rate ($35,274.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13064.4473","35274.20","35274.20","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","37250.76","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","32062.78","","Fee schedule rate ($32,062.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32062.78","32062.78","32062.78","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","28804.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18262.63","","Standard inlier is a Case rate ($18,262.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,089, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,592.30) for the length of stay and the standard reimbursement.","18262.62","18262.62","18262.62","1 through 10","7526.43","55430.66","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","28804.66","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","15042.70","","Fee schedule rate ($15,042.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8359.87","8359.87","8359.87","1 through 10","7526.43","55430.66","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","41213.39","30910.04","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","10967.66","","Case rate ($10,967.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,266.77, add-ons for qualifying new technology services are included. If operating cost exceeds $56,409.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,780.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,129.53. The transfer operating threshold is the transfer adjustment factor * $11,266.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.14. The transfer capital threshold is the transfer adjustment factor * $838.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10680.16","10680.16","10680.16","1 through 10","10748.31","12247.5265","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","41213.39","30910.04","MEDICARE [2001]","HB NWH MEDICARE","10967.66","","Case rate ($10,967.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,266.77, add-ons for qualifying new technology services are included. If operating cost exceeds $56,409.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,780.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,129.53. The transfer operating threshold is the transfer adjustment factor * $11,266.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.14. The transfer capital threshold is the transfer adjustment factor * $838.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11820.45","11820.45","11841.70","1 through 10","10748.31","12247.5265","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","41213.39","30910.04","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10748.31","","Case rate ($10,967.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,266.77, add-ons for qualifying new technology services are included. If operating cost exceeds $56,409.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,780.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,129.53. The transfer operating threshold is the transfer adjustment factor * $11,266.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.14. The transfer capital threshold is the transfer adjustment factor * $838.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10560.08","10560.08","10560.08","1 through 10","10748.31","12247.5265","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","37744.91","28308.68","MEDICARE [2001]","HB NWH MEDICARE","19129.08","","Case rate ($19,129.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,650.76, add-ons for qualifying new technology services are included. If operating cost exceeds $64,793.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,403.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $17,667.26. The transfer operating threshold is the transfer adjustment factor * $19,650.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,461.82. The transfer capital threshold is the transfer adjustment factor * $1,461.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21898.31","21898.31","21898.31","1 through 10","18746.5","22664.09","other","Inpatient Replacement Plans DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","61077.65","45808.24","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","27067.80","","Case rate ($26,279.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,996.10, add-ons for qualifying new technology services are included. If operating cost exceeds $72,138.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,950.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $24,271.17. The transfer operating threshold is the transfer adjustment factor * $26,996.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,008.25. The transfer capital threshold is the transfer adjustment factor * $2,008.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","29264.14","29264.14","29264.14","1 through 10","25753.83","31135.8","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","61077.65","45808.24","MEDICARE [2001]","HB NWH MEDICARE","26279.42","","Case rate ($26,279.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,996.10, add-ons for qualifying new technology services are included. If operating cost exceeds $72,138.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,950.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $24,271.17. The transfer operating threshold is the transfer adjustment factor * $26,996.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,008.25. The transfer capital threshold is the transfer adjustment factor * $2,008.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31253.12","31253.12","31253.12","1 through 10","25753.83","31135.8","other","Inpatient Replacement Plans DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","61077.65","45808.24","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","25753.83","","Case rate ($26,279.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,996.10, add-ons for qualifying new technology services are included. If operating cost exceeds $72,138.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,950.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $24,271.17. The transfer operating threshold is the transfer adjustment factor * $26,996.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,008.25. The transfer capital threshold is the transfer adjustment factor * $2,008.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","27895.29","27895.29","27895.29","1 through 10","25753.83","31135.8","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","17213.21","","Case rate ($16,711.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $15,434.74. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","16904.28","16883.36","16920.99","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","18375.10","","Case rate ($18,375.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,097.99. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16264.44","16264.44","16264.44","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","ELDER SERVICES [1037]","HB NWH MEDICARE","18375.10","","Case rate ($18,375.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,097.99. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16070.67","16070.67","16070.67","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","FALLON HEALTH [1008]","HB NWH MEDICARE","18375.10","","Case rate ($18,375.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,097.99. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16399.64","16399.64","16399.64","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","MEDICARE [2001]","HB NWH MEDICARE","18375.10","","Case rate ($18,375.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,097.99. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17995.54","17995.31","18027.89","103","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","16377.61","","Case rate ($16,711.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $15,434.74. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","16088.37","16077.87","16093.87","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","46890.49","35167.87","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16377.61","","Case rate ($16,711.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,167.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,309.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,219.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $15,434.74. The transfer operating threshold is the transfer adjustment factor * $17,167.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.10. The transfer capital threshold is the transfer adjustment factor * $1,277.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","16090.05","16079.78","16116.25","1 through 10","16377.61","18645.7095","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","63927.72","47945.79","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","26405.67","","Case rate ($26,405.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,670.47, add-ons for qualifying new technology services are included. If operating cost exceeds $69,812.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,777.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $24,570.44. The transfer operating threshold is the transfer adjustment factor * $24,670.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.24. The transfer capital threshold is the transfer adjustment factor * $1,835.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21980.93","21980.93","23974.35","1 through 10","23535.22","28453.55","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","63927.72","47945.79","MEDICARE [2001]","HB NWH MEDICARE","26405.67","","Case rate ($26,405.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,670.47, add-ons for qualifying new technology services are included. If operating cost exceeds $69,812.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,777.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $24,570.44. The transfer operating threshold is the transfer adjustment factor * $24,670.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.24. The transfer capital threshold is the transfer adjustment factor * $1,835.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24364.18","24320.45","24364.18","15","23535.22","28453.55","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","63927.72","47945.79","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","23535.22","","Case rate ($24,015.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,670.47, add-ons for qualifying new technology services are included. If operating cost exceeds $69,812.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,777.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $22,180.29. The transfer operating threshold is the transfer adjustment factor * $24,670.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.24. The transfer capital threshold is the transfer adjustment factor * $1,835.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21728.17","21728.17","21728.17","1 through 10","23535.22","28453.55","other","Inpatient DRG"
"Major Large Bowel Procedures,EXTREME","231","DRG","","","","","","","","inpatient","","","64501.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","68207.69","","Fee schedule rate ($68,207.69). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($7,892.03) multiplied by length of stay and the outlier percent (100%).","25879.38","25879.38","25879.38","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,EXTREME","231","DRG","","","","","","","","inpatient","","","64501.62","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","127315.27","","Fee schedule rate ($127,315.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","127315.27","127315.27","127315.27","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","55836.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","63496.30","","Standard inlier is a Case rate ($63,496.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $76,789, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,013.55) for the length of stay and the standard reimbursement.","60617.02","60617.02","60617.02","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","55836.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","68207.69","","Standard inlier is a Case rate ($68,207.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $76,789, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,681.79) for the length of stay and the standard reimbursement.","68207.69","15064.02","68207.69","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","36176.79","","Standard inlier is a Case rate ($36,176.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,761, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,135.44) for the length of stay and the standard reimbursement.","36176.78","36176.78","36176.78","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38861.08","","Standard inlier is a Case rate ($38,861.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,761, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,516.17) for the length of stay and the standard reimbursement.","38861.08","37094.67","79656.72","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","MASSHEALTH [3001]","HB NWH MEDICAID","11841.77","","Case rate ($12,757.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,187.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13279.73","13279.73","13279.73","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","15092.73","","Fee schedule rate ($15,092.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15092.78","15092.78","15092.78","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","17756.21","","Fee schedule rate ($17,756.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17756.21","17756.21","17756.21","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","48618.04","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37845.56","","Fee schedule rate ($37,845.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37845.56","37845.56","37845.56","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","58707.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","44421.18","","Standard inlier is a Case rate ($44,421.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,305.76) for the length of stay and the standard reimbursement.","44421.18","4906.89","47717.20","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","58707.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47717.21","","Standard inlier is a Case rate ($47,717.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,773.26) for the length of stay and the standard reimbursement.","45548.24","5521.16","47717.20","12","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","58707.48","","MASSHEALTH [3001]","HB NWH MEDICAID","14953.57","","Case rate ($16,110.11). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,540.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16769.42","16769.42","16769.42","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","58707.48","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","21749.13","","Fee schedule rate ($21,749.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21749.13","21749.13","21749.13","1 through 10","11841.77","127315.27","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","58707.48","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46356.08","","Fee schedule rate ($46,356.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46356.08","46356.08","46356.08","1 through 10","11841.77","127315.27","case rate",""
"Major Male Pelvic Procedures With Cc/McC","707","MS-DRG","","","","","","","","inpatient","","","41349.93","31012.45","MEDICARE [2001]","HB NWH MEDICARE","19055.27","","Case rate ($19,055.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,803.08, add-ons for qualifying new technology services are included. If operating cost exceeds $62,945.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,266.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $17,730.89. The transfer operating threshold is the transfer adjustment factor * $17,803.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.38. The transfer capital threshold is the transfer adjustment factor * $1,324.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18521.42","18521.42","18521.42","1 through 10","16983.85","19190.5934","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","40600.27","30450.20","MEDICARE [2001]","HB NWH MEDICARE","14615.11","","Case rate ($14,615.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,654.70, add-ons for qualifying new technology services are included. If operating cost exceeds $58,796.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,957.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $13,599.32. The transfer operating threshold is the transfer adjustment factor * $13,654.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.78. The transfer capital threshold is the transfer adjustment factor * $1,015.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12363.95","12363.95","12363.95","1 through 10","13026.36","14615.11","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","40600.27","30450.20","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13026.36","","Case rate ($13,292.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,654.70, add-ons for qualifying new technology services are included. If operating cost exceeds $58,796.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,957.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,276.42. The transfer operating threshold is the transfer adjustment factor * $13,654.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.78. The transfer capital threshold is the transfer adjustment factor * $1,015.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12676.23","12676.23","12676.23","1 through 10","13026.36","14615.11","other","Inpatient DRG"
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","36751.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40312.09","","Standard inlier is a Case rate ($40,312.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $50,146, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,722.13) for the length of stay and the standard reimbursement.","40312.08","40312.08","40312.08","1 through 10","13934.58","71771.92","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","42795.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","53189.41","","Fee schedule rate ($53,189.41). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($6,154.33) multiplied by length of stay and the outlier percent (100%).","6154.33","6154.33","6154.33","1 through 10","13934.58","71771.92","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","42795.39","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","47847.95","","Fee schedule rate ($47,847.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47847.95","47847.95","47847.95","1 through 10","13934.58","71771.92","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","46413.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32046.01","","Standard inlier is a Case rate ($32,046.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,549.06) for the length of stay and the standard reimbursement.","42007.30","42007.30","42007.30","1 through 10","11623.57","73426.04","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","46413.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34423.80","","Standard inlier is a Case rate ($34,423.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,886.31) for the length of stay and the standard reimbursement.","45118.40","45118.40","45118.40","1 through 10","11623.57","73426.04","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","44961.52","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","33348.423","","Fee schedule rate ($44,501.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33348.423","42786.32","42786.32","1 through 10","11623.57","73426.04","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","37076.49","","Standard inlier is a Case rate ($37,076.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,684, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,263.15) for the length of stay and the standard reimbursement.","35397.17","35395.01","37076.48","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39827.54","","Standard inlier is a Case rate ($39,827.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,684, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,653.35) for the length of stay and the standard reimbursement.","38017.19","38017.19","38017.19","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20802.459","","Fee schedule rate ($54,039.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20802.459","54039.50","54039.50","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","21842.4755","","Fee schedule rate ($56,741.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21842.4755","56741.20","56741.20","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","MASSHEALTH [3001]","HB NWH MEDICAID","14359.54","","Case rate ($15,470.14). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,900.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15509.92","15509.92","25375.66","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","52406.44","","Fee schedule rate ($52,406.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52406.44","52406.44","52406.44","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","47759.06","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","14359.54","","Case rate ($15,470.14). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,900.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2390.92","2390.92","2390.92","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","36093.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25667.21","","Standard inlier is a Case rate ($25,667.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,643.56) for the length of stay and the standard reimbursement.","24502.88","24502.88","24503.22","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","36093.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27571.70","","Standard inlier is a Case rate ($27,571.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,913.69) for the length of stay and the standard reimbursement.","26322.12","26318.43","63719.69","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","36093.17","","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICAID","8346.13","","Case rate ($8,991.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,421.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17282.50","17282.50","17282.50","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","36093.17","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23423.11","","Fee schedule rate ($23,423.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32741.11","32741.11","32741.11","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","36093.17","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8346.13","","Case rate ($8,991.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,421.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9014.76","9014.76","11268.45","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MINOR","137","DRG","","","","","","","","inpatient","","","14896.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15871.50","","Standard inlier is a Case rate ($15,871.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,806, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,252.89) for the length of stay and the standard reimbursement.","15150.06","15150.06","15151.55","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MINOR","137","DRG","","","","","","","","inpatient","","","14896.04","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20802.459","","Fee schedule rate ($20,802.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20802.459","20802.46","20802.46","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","15548.58","","MASSHEALTH [3001]","HB NWH MEDICAID","6895.32","","Case rate ($7,428.62). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,858.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7447.72","7447.72","7447.72","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","15548.58","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10989.49","","Fee schedule rate ($10,989.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11032.84","11032.84","11032.84","1 through 10","5034.41","89164.33","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","15548.58","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6895.32","","Case rate ($7,428.62). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,858.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3467.30","3467.30","3467.30","1 through 10","5034.41","89164.33","case rate",""
"Major Shoulder Or Elbow Joint Procedures With Cc/McC","507","MS-DRG","","","","","","","","inpatient","","","28179.58","21134.68","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15337.51","","Case rate ($15,650.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,077.33, add-ons for qualifying new technology services are included. If operating cost exceeds $61,219.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,137.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,454.52. The transfer operating threshold is the transfer adjustment factor * $16,077.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.00. The transfer capital threshold is the transfer adjustment factor * $1,196.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16541.29","16541.29","16541.29","1 through 10","15337.51","18542.7","other","Inpatient DRG"
"Major Skin Disorders With McC","595","MS-DRG","","","","","","","","inpatient","","","31822.08","23866.56","MEDICARE [2001]","HB NWH MEDICARE","18373.58","","Case rate ($18,373.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,874.66, add-ons for qualifying new technology services are included. If operating cost exceeds $64,016.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,346.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $16,969.50. The transfer operating threshold is the transfer adjustment factor * $18,874.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.09. The transfer capital threshold is the transfer adjustment factor * $1,404.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20223.16","20223.16","20223.16","1 through 10","18006.11","20971.6023","other","Inpatient Replacement Plans DRG"
"Major Skin Disorders With McC","595","MS-DRG","","","","","","","","inpatient","","","31822.08","23866.56","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","18006.11","","Case rate ($18,373.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,874.66, add-ons for qualifying new technology services are included. If operating cost exceeds $64,016.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,346.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $16,969.50. The transfer operating threshold is the transfer adjustment factor * $18,874.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.09. The transfer capital threshold is the transfer adjustment factor * $1,404.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18036.96","18036.96","18036.96","1 through 10","18006.11","20971.6023","other","Inpatient DRG"
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","14504.16","10878.12","ELDER SERVICES [1037]","HB NWH MEDICARE","9378.71","","Case rate ($9,378.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,634.47, add-ons for qualifying new technology services are included. If operating cost exceeds $54,776.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,658.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,661.99. The transfer operating threshold is the transfer adjustment factor * $9,634.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.71. The transfer capital threshold is the transfer adjustment factor * $716.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22750.78","22750.78","22750.78","1 through 10","9191.14","11111.86","other","Inpatient Replacement Plans DRG"
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","14504.16","10878.12","MEDICARE [2001]","HB NWH MEDICARE","9378.71","","Case rate ($9,378.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,634.47, add-ons for qualifying new technology services are included. If operating cost exceeds $54,776.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,658.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,661.99. The transfer operating threshold is the transfer adjustment factor * $9,634.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.71. The transfer capital threshold is the transfer adjustment factor * $716.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10318.20","10318.20","10318.20","1 through 10","9191.14","11111.86","other","Inpatient Replacement Plans DRG"
"Major Skin Disorders,MINOR","381","DRG","","","","","","","","inpatient","","","13824.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9535.54","","Standard inlier is a Case rate ($9,535.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,754, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,353.53) for the length of stay and the standard reimbursement.","9535.54","9535.54","9535.54","1 through 10","4288.81","28461.78","case rate",""
"Major Skin Disorders,MINOR","381","DRG","","","","","","","","inpatient","","","13824.39","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","10754.50","","Fee schedule rate ($10,754.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10754.50","10754.50","10754.50","1 through 10","4288.81","28461.78","case rate",""
"Major Skin Disorders,MODERATE","381","DRG","","","","","","","","inpatient","","","18078.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","17257.37","","Fee schedule rate ($17,257.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17257.37","17257.37","17257.37","1 through 10","4288.81","28461.78","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","71733.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29137.122","","Fee schedule rate ($64,285.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29137.122","64285.36","64285.36","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","71733.22","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","30593.829","","Fee schedule rate ($67,499.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30593.829","67499.32","67499.32","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","71733.22","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","70713.24","","Fee schedule rate ($70,713.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70713.24","70713.24","70713.24","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","71733.22","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","67499.30","","Fee schedule rate ($67,499.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67499.30","67499.30","67499.30","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","44438.19","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29137.122","","Fee schedule rate ($29,137.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29137.122","29137.12","29137.12","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","44438.19","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","30593.829","","Fee schedule rate ($30,593.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30593.829","30593.84","30593.84","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","44438.19","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","32050.54","","Fee schedule rate ($32,050.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32050.54","32050.54","32050.54","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","55548.38","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29137.122","","Fee schedule rate ($38,030.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29137.122","38030.68","38030.68","1 through 10","23930.55","228645.43","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","55548.38","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","30593.829","","Fee schedule rate ($39,932.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30593.829","39932.04","39932.04","1 through 10","23930.55","228645.43","case rate",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","20769.17","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20383.28","20383.28","20389.41","1 through 10","20353.79","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","20769.17","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9436.70","9436.70","9436.70","1 through 10","20353.79","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","HUMANA [1012]","HB NWH MEDICARE","20769.17","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5904.22","5904.22","5904.22","1 through 10","20353.79","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","MEDICARE [2001]","HB NWH MEDICARE","20769.17","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22559.56","13810.96","22600.11","49","20353.79","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","20353.79","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20160.11","16474.60","20189.11","1 through 10","20353.79","23374.6293","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","55718.63","41788.97","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20353.79","","Case rate ($20,769.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,335.57, add-ons for qualifying new technology services are included. If operating cost exceeds $66,477.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,529.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,182.01. The transfer operating threshold is the transfer adjustment factor * $21,335.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,587.16. The transfer capital threshold is the transfer adjustment factor * $1,587.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20152.01","20152.01","20154.11","1 through 10","20353.79","23374.6293","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","71864.62","53898.46","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","41018.46","","Case rate ($39,823.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,909.80, add-ons for qualifying new technology services are included. If operating cost exceeds $86,052.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,985.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $36,780.45. The transfer operating threshold is the transfer adjustment factor * $40,909.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,043.29. The transfer capital threshold is the transfer adjustment factor * $3,043.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25735.43","25735.43","25735.43","1 through 10","39027.28","45409.2991","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","71864.62","53898.46","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","43787.21","","Case rate ($43,787.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,909.80, add-ons for qualifying new technology services are included. If operating cost exceeds $86,052.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,985.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $40,743.90. The transfer operating threshold is the transfer adjustment factor * $40,909.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,043.29. The transfer capital threshold is the transfer adjustment factor * $3,043.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39598.08","39598.08","39610.00","1 through 10","39027.28","45409.2991","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","71864.62","53898.46","MEDICARE [2001]","HB NWH MEDICARE","43787.21","","Case rate ($43,787.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,909.80, add-ons for qualifying new technology services are included. If operating cost exceeds $86,052.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,985.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $40,743.90. The transfer operating threshold is the transfer adjustment factor * $40,909.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,043.29. The transfer capital threshold is the transfer adjustment factor * $3,043.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43825.87","13720.20","43904.66","20","39027.28","45409.2991","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","71864.62","53898.46","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","39027.28","","Case rate ($39,823.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,909.80, add-ons for qualifying new technology services are included. If operating cost exceeds $86,052.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,985.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $36,780.45. The transfer operating threshold is the transfer adjustment factor * $40,909.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,043.29. The transfer capital threshold is the transfer adjustment factor * $3,043.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39176.02","39176.02","39176.02","1 through 10","39027.28","45409.2991","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","71864.62","53898.46","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","39027.28","","Case rate ($39,823.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,909.80, add-ons for qualifying new technology services are included. If operating cost exceeds $86,052.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,985.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $36,780.45. The transfer operating threshold is the transfer adjustment factor * $40,909.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,043.29. The transfer capital threshold is the transfer adjustment factor * $3,043.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39161.56","39155.86","39167.89","1 through 10","39027.28","45409.2991","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","48966.11","36724.58","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14580.52","","Case rate ($14,580.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,978.16, add-ons for qualifying new technology services are included. If operating cost exceeds $60,120.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,056.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,466.29. The transfer operating threshold is the transfer adjustment factor * $14,978.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.23. The transfer capital threshold is the transfer adjustment factor * $1,114.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15533.19","15533.19","15533.19","1 through 10","14288.91","17274.97","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","48966.11","36724.58","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","24974.86","24974.86","24974.86","1 through 10","14288.91","17274.97","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","48966.11","36724.58","MEDICARE [2001]","HB NWH MEDICARE","14580.52","","Case rate ($14,580.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,978.16, add-ons for qualifying new technology services are included. If operating cost exceeds $60,120.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,056.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,466.29. The transfer operating threshold is the transfer adjustment factor * $14,978.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.23. The transfer capital threshold is the transfer adjustment factor * $1,114.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15785.76","15757.23","15785.76","21","14288.91","17274.97","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","48966.11","36724.58","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14288.91","","Case rate ($14,580.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,978.16, add-ons for qualifying new technology services are included. If operating cost exceeds $60,120.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,056.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,466.29. The transfer operating threshold is the transfer adjustment factor * $14,978.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.23. The transfer capital threshold is the transfer adjustment factor * $1,114.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14089.01","14089.01","14089.01","1 through 10","14288.91","17274.97","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","48966.11","36724.58","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14288.91","","Case rate ($14,580.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,978.16, add-ons for qualifying new technology services are included. If operating cost exceeds $60,120.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,056.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,466.29. The transfer operating threshold is the transfer adjustment factor * $14,978.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.23. The transfer capital threshold is the transfer adjustment factor * $1,114.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14088.81","14088.81","14088.81","1 through 10","14288.91","17274.97","other","Inpatient DRG"
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","125499.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","118321.65","","Standard inlier is a Case rate ($118,321.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $133,033, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,796.22) for the length of stay and the standard reimbursement.","26140.32","26140.32","26140.32","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","125499.29","","MASSHEALTH [3001]","HB NWH MEDICAID","57566.11","","Case rate ($62,018.39). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $104,448.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","62177.88","62177.88","62177.88","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","73280.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","69081.98","","Standard inlier is a Case rate ($69,081.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $77,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,805.90) for the length of stay and the standard reimbursement.","69081.98","69081.98","69081.98","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","73280.51","","MASSHEALTH [3001]","HB NWH MEDICAID","26946.13","","Case rate ($29,030.20). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $71,460.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29104.85","29104.85","29104.85","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","73280.51","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84182.76","","Fee schedule rate ($84,182.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","84182.76","84182.76","84182.76","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","73280.51","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","26946.13","","Case rate ($29,030.20). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $71,460.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29104.86","29104.86","29104.86","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","77892.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31670.93","","Standard inlier is a Case rate ($31,670.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,495.81) for the length of stay and the standard reimbursement.","30236.74","30236.74","30236.74","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","29596.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43425.87","","Standard inlier is a Case rate ($43,425.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,164.47) for the length of stay and the standard reimbursement.","43425.87","43425.87","43425.87","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","29596.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46648.05","","Standard inlier is a Case rate ($46,648.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,621.49) for the length of stay and the standard reimbursement.","44527.68","5397.45","46648.04","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","29596.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","25696.01","","Fee schedule rate ($25,696.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25696.01","25696.01","25696.01","1 through 10","11556.71","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","29596.22","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","54768.06","","Fee schedule rate ($54,768.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54768.06","54768.06","54768.06","1 through 10","11556.71","169330.14","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","617305.56","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","25911.3932","","Fee schedule rate ($163,431.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25911.3932","283657.27","283657.27","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","71841.93","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","92420.70","","Fee schedule rate ($92,420.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","92420.70","92420.70","92420.70","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","33820.89","","Standard inlier is a Case rate ($33,820.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,801.01) for the length of stay and the standard reimbursement.","33820.89","32286.00","33820.89","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36330.39","","Standard inlier is a Case rate ($36,330.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,156.94) for the length of stay and the standard reimbursement.","36330.38","36330.38","36330.38","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24677.6376","","Fee schedule rate ($24,677.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24677.6376","24677.64","24677.64","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","27145.15","","Fee schedule rate ($27,145.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27145.16","27145.16","27145.16","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","16712.77","","Fee schedule rate ($16,712.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16712.88","16712.88","16712.88","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","33134.32","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","41910.05","","Fee schedule rate ($41,910.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41910.05","41910.05","41910.05","1 through 10","10892.46","256820.24","case rate",""
"Male Reproductive System Diagnoses Except Malignancy,MAJOR","501","DRG","","","","","","","","inpatient","","","64708.45","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8732.25","","Case rate ($9,407.62). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,837.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9431.81","9431.81","9431.81","1 through 10","4318.14","34626.83","case rate",""
"Male Reproductive System Diagnoses Except Malignancy,MODERATE","501","DRG","","","","","","","","inpatient","","","30708.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15534.43","","Standard inlier is a Case rate ($15,534.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,484, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,205.05) for the length of stay and the standard reimbursement.","14828.31","14828.31","14828.31","1 through 10","4318.14","34626.83","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","109577.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","56244.51","","Fee schedule rate ($56,244.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","56244.51","56244.51","56244.51","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","28320.05","","MASSHEALTH [3001]","HB NWH MEDICAID","12415.23","","Case rate ($13,375.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $55,805.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13409.85","13409.85","13409.85","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","28320.05","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","26048.29","","Fee schedule rate ($26,048.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26048.29","26048.29","26048.29","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","18657.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13583.76","","Standard inlier is a Case rate ($13,583.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,928.27) for the length of stay and the standard reimbursement.","13583.76","13583.76","13583.76","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20932.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16814.84","","Standard inlier is a Case rate ($16,814.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,386.93) for the length of stay and the standard reimbursement.","16814.83","16814.83","16814.83","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20932.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18062.49","","Standard inlier is a Case rate ($18,062.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,563.89) for the length of stay and the standard reimbursement.","18062.49","18062.49","18062.49","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20932.02","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7653.85","","Case rate ($8,245.82). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,675.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8267.02","8267.02","8267.02","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,EXTREME","206","DRG","","","","","","","","inpatient","","","17788.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10253.6874","","Fee schedule rate ($53,484.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10253.6874","24758.94","24758.94","1 through 10","2757","88248.6","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","20673.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23196.09","","Standard inlier is a Case rate ($23,196.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,443, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,292.78) for the length of stay and the standard reimbursement.","3143.27","3143.27","3143.27","1 through 10","2757","88248.6","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","20673.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24917.23","","Standard inlier is a Case rate ($24,917.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,443, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,536.90) for the length of stay and the standard reimbursement.","23784.62","23784.62","23784.62","1 through 10","2757","88248.6","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MODERATE","206","DRG","","","","","","","","inpatient","","","30976.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16619.39","","Standard inlier is a Case rate ($16,619.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,520, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,359.05) for the length of stay and the standard reimbursement.","7077.15","7077.15","7077.15","1 through 10","2757","88248.6","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","34645.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","37220.48","","Standard inlier is a Case rate ($37,220.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $47,194, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,283.29) for the length of stay and the standard reimbursement.","37220.47","37220.47","37220.47","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","34645.67","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8890.8827","","Fee schedule rate ($53,767.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8890.8827","56328.12","56328.12","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","34645.67","","MASSHEALTH [3001]","HB NWH MEDICAID","14811.92","","Case rate ($15,957.50). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,387.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,988.30 and the sum of the standard inlier and any outlier amount.","15998.54","821.56","15998.54","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","34645.67","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","14811.92","","Case rate ($15,957.50). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,387.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,988.30 and the sum of the standard inlier and any outlier amount.","15998.54","15998.54","15998.54","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","25893.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20693.11","","Standard inlier is a Case rate ($20,693.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,937.47) for the length of stay and the standard reimbursement.","19752.78","19752.78","19752.78","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","25893.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22228.53","","Standard inlier is a Case rate ($22,228.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,155.25) for the length of stay and the standard reimbursement.","21218.14","21218.14","22228.52","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","25893.85","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8467.5486","","Fee schedule rate ($24,114.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8467.5486","24114.82","24114.83","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","25893.85","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8890.8827","","Fee schedule rate ($25,320.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8890.8827","21522.19","21522.19","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","25893.85","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","24278.74","","Fee schedule rate ($24,278.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16370.77","16370.77","16370.77","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","26075.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14561.91","","Standard inlier is a Case rate ($14,561.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,067.12) for the length of stay and the standard reimbursement.","10923.68","10923.68","13900.19","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","26075.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15642.40","","Standard inlier is a Case rate ($15,642.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,220.37) for the length of stay and the standard reimbursement.","14931.37","14931.37","14931.37","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","26075.19","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8467.5486","","Fee schedule rate ($13,519.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8467.5486","13519.16","13519.16","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","26075.19","","MASSHEALTH [3001]","HB NWH MEDICAID","5458.22","","Case rate ($5,880.38). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,310.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5895.49","5895.49","5895.49","1 through 10","4537.48","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,EXTREME","349","DRG","","","","","","","","inpatient","","","27028.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","45568.48","","Standard inlier is a Case rate ($45,568.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $58,396, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,468.62) for the length of stay and the standard reimbursement.","19405.87","19405.87","19405.87","1 through 10","1960","48949.64","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","17277.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27516.40","","Fee schedule rate ($27,516.40). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,183.81) multiplied by length of stay and the outlier percent (100%).","7811.67","7811.67","7811.67","1 through 10","1960","48949.64","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","17277.04","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10060.2216","","Per diem ($6,603). If length of stay < 5, first 1 days paid at a per diem of $13,206 instead.","10060.2216","13206.48","13206.48","1 through 10","1960","48949.64","per diem","Estimated amount calculated based on 1 day length of stay."
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MINOR","349","DRG","","","","","","","","inpatient","","","19955.57","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13527.78","","Standard inlier is a Case rate ($13,527.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,568, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,920.21) for the length of stay and the standard reimbursement.","12912.87","12912.87","12912.87","1 through 10","1960","48949.64","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","17836.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19155.35","","Standard inlier is a Case rate ($19,155.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,943, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,719.02) for the length of stay and the standard reimbursement.","19155.35","19155.35","19155.35","1 through 10","1960","48949.64","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","53130.07","","MASSHEALTH [3001]","HB NWH MEDICAID","18556.59","","Case rate ($19,991.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,421.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25393.07","25393.07","25393.07","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","40695.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25760.36","","Standard inlier is a Case rate ($25,760.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,656.78) for the length of stay and the standard reimbursement.","24589.77","24589.77","24589.77","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","40695.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27671.77","","Standard inlier is a Case rate ($27,671.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,927.89) for the length of stay and the standard reimbursement.","27671.76","27671.76","27671.76","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MINOR","281","DRG","","","","","","","","inpatient","","","18494.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16034.77","","Standard inlier is a Case rate ($16,034.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,961, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,276.07) for the length of stay and the standard reimbursement.","15305.91","15305.91","15305.91","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MODERATE","281","DRG","","","","","","","","inpatient","","","27826.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21264.71","","Standard inlier is a Case rate ($21,264.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,955, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,018.44) for the length of stay and the standard reimbursement.","21264.70","21264.70","21264.70","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MODERATE","281","DRG","","","","","","","","inpatient","","","27826.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15053.2026","","Fee schedule rate ($28,808.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15053.2026","18592.26","18592.26","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MODERATE","281","DRG","","","","","","","","inpatient","","","27826.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29920.7562","","Fee schedule rate ($28,808.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29920.7562","18592.26","18592.26","1 through 10","7119.22","85959.28","case rate",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","24203.00","18152.25","MEDICARE [2001]","HB NWH MEDICARE","10775.08","","Case rate ($10,775.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,067.02, add-ons for qualifying new technology services are included. If operating cost exceeds $55,209.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,690.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,026.20. The transfer operating threshold is the transfer adjustment factor * $10,067.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $748.89. The transfer capital threshold is the transfer adjustment factor * $748.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10782.31","10782.31","10782.31","1 through 10","9603.76","11151.8253","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","24203.00","18152.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9603.76","","Case rate ($9,799.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,067.02, add-ons for qualifying new technology services are included. If operating cost exceeds $55,209.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,690.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,050.88. The transfer operating threshold is the transfer adjustment factor * $10,067.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $748.89. The transfer capital threshold is the transfer adjustment factor * $748.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9643.35","9643.35","9643.35","1 through 10","9603.76","11151.8253","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","24203.00","18152.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9603.76","","Case rate ($9,799.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,067.02, add-ons for qualifying new technology services are included. If operating cost exceeds $55,209.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,690.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,050.88. The transfer operating threshold is the transfer adjustment factor * $10,067.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $748.89. The transfer capital threshold is the transfer adjustment factor * $748.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9637.85","9637.85","9637.85","1 through 10","9603.76","11151.8253","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","45797.92","34348.44","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","16390.42","","Case rate ($15,913.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,347, add-ons for qualifying new technology services are included. If operating cost exceeds $61,489.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,158.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,696.98. The transfer operating threshold is the transfer adjustment factor * $16,347.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.06. The transfer capital threshold is the transfer adjustment factor * $1,216.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16366.94","16366.94","16366.94","1 through 10","15594.77","18043.4694","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","45797.92","34348.44","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","15913.03","","Case rate ($15,913.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,347, add-ons for qualifying new technology services are included. If operating cost exceeds $61,489.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,158.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,696.98. The transfer operating threshold is the transfer adjustment factor * $16,347.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.06. The transfer capital threshold is the transfer adjustment factor * $1,216.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15739.10","15739.10","15739.10","1 through 10","15594.77","18043.4694","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","45797.92","34348.44","MEDICARE [2001]","HB NWH MEDICARE","15913.03","","Case rate ($15,913.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,347, add-ons for qualifying new technology services are included. If operating cost exceeds $61,489.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,158.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,696.98. The transfer operating threshold is the transfer adjustment factor * $16,347.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.06. The transfer capital threshold is the transfer adjustment factor * $1,216.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17445.59","17414.05","17445.59","11","15594.77","18043.4694","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","45797.92","34348.44","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15594.77","","Case rate ($15,913.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,347, add-ons for qualifying new technology services are included. If operating cost exceeds $61,489.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,158.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,696.98. The transfer operating threshold is the transfer adjustment factor * $16,347.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,216.06. The transfer capital threshold is the transfer adjustment factor * $1,216.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","119.33","119.33","26788.74","1 through 10","15594.77","18043.4694","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","27082.51","20311.88","MEDICARE [2001]","HB NWH MEDICARE","10362.60","","Case rate ($10,362.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,681.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,823.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,662.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,642.38. The transfer operating threshold is the transfer adjustment factor * $9,681.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.22. The transfer capital threshold is the transfer adjustment factor * $720.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10614.04","10614.04","10614.04","1 through 10","954.59","10977.7789","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","27082.51","20311.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9236.13","","Case rate ($9,424.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,681.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,823.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,662.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,704.40. The transfer operating threshold is the transfer adjustment factor * $9,681.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.22. The transfer capital threshold is the transfer adjustment factor * $720.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9481.30","9481.30","10458.74","1 through 10","954.59","10977.7789","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","27082.51","20311.88","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9236.13","","Case rate ($9,424.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,681.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,823.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,662.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,704.40. The transfer operating threshold is the transfer adjustment factor * $9,681.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.22. The transfer capital threshold is the transfer adjustment factor * $720.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9942.48","9942.48","9942.48","1 through 10","954.59","10977.7789","other","Inpatient DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","45177.83","33883.37","MEDICARE [2001]","HB NWH MEDICARE","17544.41","","Case rate ($17,544.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,391.51, add-ons for qualifying new technology services are included. If operating cost exceeds $61,533.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,161.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,325.04. The transfer operating threshold is the transfer adjustment factor * $16,391.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,219.37. The transfer capital threshold is the transfer adjustment factor * $1,219.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17268.27","17268.27","17268.27","1 through 10","954.59","18905.05","other","Inpatient DRG"
"Malignancy, Male Reproductive System With McC","722","MS-DRG","","","","","","","","inpatient","","","17256.91","12942.68","MEDICARE [2001]","HB NWH MEDICARE","17239.58","","Case rate ($17,239.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,106.70, add-ons for qualifying new technology services are included. If operating cost exceeds $61,248.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,140.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $16,041.39. The transfer operating threshold is the transfer adjustment factor * $16,106.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,198.18. The transfer capital threshold is the transfer adjustment factor * $1,198.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16530.58","16530.58","16530.58","1 through 10","15365.54","18576.57","other","Inpatient DRG"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","","","","inpatient","","","21952.94","16464.70","MEDICARE [2001]","HB NWH MEDICARE","10776.99","","Case rate ($10,776.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,068.80, add-ons for qualifying new technology services are included. If operating cost exceeds $55,211.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,690.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,027.97. The transfer operating threshold is the transfer adjustment factor * $10,068.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $749.02. The transfer capital threshold is the transfer adjustment factor * $749.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10297.20","10297.20","10315.71","1 through 10","9605.47","10776.99","other","Inpatient DRG"
"Malignant Breast Disorders With McC","597","MS-DRG","","","","","","","","inpatient","","","28138.07","21103.55","MEDICARE [2001]","HB NWH MEDICARE","14443.63","","Case rate ($14,443.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,837.53, add-ons for qualifying new technology services are included. If operating cost exceeds $59,979.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,045.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,339.86. The transfer operating threshold is the transfer adjustment factor * $14,837.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,103.77. The transfer capital threshold is the transfer adjustment factor * $1,103.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16796.39","16796.39","16796.39","1 through 10","14154.76","17112.78","other","Inpatient Replacement Plans DRG"
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,EXTREME","421","DRG","","","","","","","","inpatient","","","34908.54","","MASSHEALTH [3001]","HB NWH MEDICAID","25955.70","","Case rate ($27,963.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $70,393.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28035.07","28035.07","28035.07","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33302.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14230.96","","Standard inlier is a Case rate ($14,230.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,246, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,020.14) for the length of stay and the standard reimbursement.","23840.37","23840.37","23840.37","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33302.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15286.89","","Standard inlier is a Case rate ($15,286.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,246, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,169.91) for the length of stay and the standard reimbursement.","23166.01","23166.01","23166.01","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33302.03","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","9302.29","","Case rate ($10,021.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,451.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,275.03 and the sum of the standard inlier and any outlier amount.","36492.79","36492.79","36492.79","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MINOR","421","DRG","","","","","","","","inpatient","","","3242.00","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11897.1696","","Fee schedule rate ($11,897.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11897.1696","11897.16","11897.16","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","26314.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11897.1696","","Fee schedule rate ($17,490.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11897.1696","17490.10","17490.10","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","26314.55","","MASSHEALTH [3001]","HB NWH MEDICAID","9302.29","","Case rate ($10,021.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,451.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10047.52","1870.98","10047.52","1 through 10","4706.35","128247.29","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","26314.55","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","9302.29","","Case rate ($10,021.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,451.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","4706.35","128247.29","case rate",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","AETNA [1001]","HB CH AETNA HMO / PPO","335.23","58.3","","316.95","316.95","316.95","107","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","419.75","73","","408.07","408.07","408.07","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","INTERNATIONAL COMMERCIAL [140001]","HB CH GMMI INTERNATIONAL","304.75","53","","558.62","558.62","558.62","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","419.75","73","","316.95","213.90","524.87","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","TRICARE [160005]","HB NWH TRICARE","546.25","95","","107.15","101.79","110.27","33","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","546.25","95","","107.15","107.15","107.15","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.59","44.45","","429.76","254.68","429.76","35","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.59","44.45","","254.68","254.68","429.76","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","331.54","2704","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","274.55","1 through 10","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","274.55","6487","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","340.98","59.3","","327.57","327.57","327.57","1117","226.79","524.54","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","451.09","78.45","","429.76","254.68","429.76","1058","226.79","524.54","percent of total billed charges",""
"Manganese","PX-30000566","CDM","83785","CPT","0301","RC","","","","both","","","290.00","217.50","AETNA [1001]","HB CH AETNA HMO / PPO","169.07","58.3","","159.89","159.89","159.89","1 through 10","26.12","275.5","percent of total billed charges",""
"Manganese","PX-30000566","CDM","83785","CPT","0301","RC","","","","outpatient","","","290.00","217.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","171.97","59.3","","165.25","165.24","165.25","1 through 10","25.36","227.51","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1313.00","984.75","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","13","231.42","1022.96","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","543.84","543.84","543.84","1 through 10","231.42","1030.05","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1313.00","984.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","583.63","44.45","","981.76","981.76","981.76","1 through 10","231.42","1030.05","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","1778.00","1333.50","AETNA [1001]","HB CH AETNA HMO / PPO","1036.57","58.3","","34.02","34.02","34.02","1 through 10","942.34","1690.88","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","1778.00","1333.50","WELLPOINT [1015]","HB CH WELLPOINT","1385.24","77.91","","47.26","47.26","47.26","1 through 10","942.34","1690.88","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1778.00","1333.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1054.35","59.3","","105.48","70.32","105.48","1 through 10","790.32","1394.84","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1778.00","1333.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.32","44.45","","26.94","26.94","26.94","1 through 10","790.32","1394.84","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1778.00","1333.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1394.84","78.45","","46.13","27.34","92.26","1 through 10","790.32","1394.84","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1778.00","1333.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.32","44.45","","46.13","46.13","46.13","1 through 10","790.32","1394.84","percent of total billed charges",""
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","3394.33","5504.11","1 through 10","1984.13","4164.87","other","Multiple Surgery"
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","both","","","4625.00","3468.75","MEDICARE [2001]","HB NWH MEDICARE","4043.56","","APC Price ($4,043.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1984.13","4164.87","other","OPPS APC"
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3818.15","3818.15","3818.15","1 through 10","2125.14","4472.66","other","ASC "
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","4472.66","other","Multiple Surgery"
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","23.63","147.25","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","265.47","88.49","265.47","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","67.80","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","23.63","147.25","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","265.47","88.49","265.47","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","67.80","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","5363.70","4022.77","AETNA [1001]","HB CH AETNA HMO / PPO","3127.04","58.3","","1862.60","353.13","2619.54","16","2384.16","4178.86","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","5363.70","4022.77","WELLPOINT [1015]","HB CH WELLPOINT","4178.86","77.91","","2876.71","1548.58","2876.71","1 through 10","2384.16","4178.86","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5363.70","4022.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","3180.67","59.3","","1151.69","270.51","3652.50","14","2681.85","4207.82","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5363.70","4022.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4207.82","78.45","","2808.04","1107.07","2808.04","12","2681.85","4207.82","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","AETNA [1001]","HB CH AETNA HMO / PPO","861.31","58.3","","2190.90","412.50","9264.59","16","656.7","1151.03","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","856.88","58","","1903.20","1903.20","3826.66","1 through 10","656.7","1151.03","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","923.36","62.5","","2186.25","2186.25","2186.25","32","656.7","1151.03","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1078.49","73","","5556.60","5556.60","5556.60","1 through 10","656.7","1151.03","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","WELLPOINT [1015]","HB CH WELLPOINT","1151.03","77.91","","1955.15","885.83","3150.40","26","656.7","1151.03","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1477.38","1108.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","876.09","59.3","","831.03","253.22","2394.88","18","738.69","1159","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1477.38","1108.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1159.00","78.45","","2481.69","1563.74","8149.28","1 through 10","738.69","1159","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","2190.90","412.50","9264.59","16","60.01","105.18","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","1903.20","1903.20","3826.66","1 through 10","60.01","105.18","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","2186.25","2186.25","2186.25","32","60.01","105.18","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","5556.60","5556.60","5556.60","1 through 10","60.01","105.18","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","1955.15","885.83","3150.40","26","60.01","105.18","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","831.03","253.22","2394.88","18","67.5","105.91","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","2481.69","1563.74","8149.28","1 through 10","67.5","105.91","percent of total billed charges",""
"MATRIX TISSUE 4X7CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287345","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","AETNA [1001]","HB CH AETNA HMO / PPO","1330.99","58.3","","52.60","33.42","52.60","1932","96.52","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287345","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","WELLPOINT [1015]","HB CH WELLPOINT","1778.69","77.91","","77.77","77.77","77.77","240","96.52","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287345","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2283.00","1712.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1191.73","52.2","","47.77","47.77","47.77","480","1141.5","1191.73","percent of total billed charges",""
"MATRIX TISSUE 5X10CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10285836","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3385.00","2538.75","AETNA [1001]","HB CH AETNA HMO / PPO","1973.46","58.3","","52.60","33.42","52.60","1932","96.52","2637.25","percent of total billed charges",""
"MATRIX TISSUE 5X10CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10285836","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3385.00","2538.75","WELLPOINT [1015]","HB CH WELLPOINT","2637.25","77.91","","77.77","77.77","77.77","240","96.52","2637.25","percent of total billed charges",""
"MATRIX TISSUE 5X10CM MED 1.6-.4MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10285836","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3385.00","2538.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1766.97","52.2","","47.77","47.77","47.77","480","1692.5","1766.97","percent of total billed charges",""
"Maximum Voluntary Ventilation (Mvv)","PX-46000023","CDM","94200","CPT","0460","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","298.29","298.29","298.29","1 through 10","175.84","313.02","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","146.50","146.50","146.50","1 through 10","55.5","222.03","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","192.20","113.90","192.20","1 through 10","55.5","222.03","percent of total billed charges",""
"Mayo, Ugtfz Ugt1a1 Full Gene Seq Udp-Glucuronosyl Transferase 1a1","PX-31001346","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","AETNA [1001]","HB CH AETNA HMO / PPO","1061.64","58.3","","1004.16","1004.16","1004.16","1 through 10","269.33","1729.95","percent of total billed charges",""
"Mayo, Ugtfz Ugt1a1 Full Gene Seq Udp-Glucuronosyl Transferase 1a1","PX-31001346","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","WELLPOINT [1015]","HB CH WELLPOINT","1418.74","77.91","","1394.84","1394.84","1394.84","1 through 10","269.33","1729.95","percent of total billed charges",""
"Mayo, Ugtfz Ugt1a1 Full Gene Seq Udp-Glucuronosyl Transferase 1a1","PX-31001346","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1079.85","59.3","","1037.81","1037.81","1037.81","1 through 10","677.46","1428.57","percent of total billed charges",""
"Mayo, Ugtfz Ugt1a1 Full Gene Seq Udp-Glucuronosyl Transferase 1a1","PX-31001346","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1428.57","78.45","","1361.55","1361.55","1361.55","1 through 10","677.46","1428.57","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","248.00","186.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.56","78.45","","185.28","185.28","185.28","12","64.82","194.56","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","outpatient","","","470.00","352.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","368.72","78.45","","351.34","351.34","351.34","1 through 10","126.08","368.72","percent of total billed charges",""
"Measles Mumps Rubella Virus Vaccine Live Subq","PX-63600317","CDM","90707","CPT","0636","RC","","","","outpatient","","","160.12","120.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","125.61","78.45","","160.12","160.12","160.12","1 through 10","80.06","125.61","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","29","60.9","404.7","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","TRICARE [160005]","HB NWH TRICARE","404.70","95","","74.88","71.14","74.88","1 through 10","60.9","404.7","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.36","44.45","","188.62","188.62","188.62","1 through 10","60.9","404.7","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","236.81","1141.80","37","176.68","603.55","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","28","176.68","603.55","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","AETNA [1001]","HB CH AETNA HMO / PPO","194.72","58.3","","184.28","184.28","368.55","45","177.02","317.63","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","211.76","63.4","","215.48","207.35","430.95","18","177.02","317.63","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","193.72","58","","164.13","164.13","164.13","1 through 10","177.02","317.63","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","193.72","58","","193.05","193.05","325.00","1 through 10","177.02","317.63","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","208.75","62.5","","208.00","208.00","624.00","41","177.02","317.63","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","192.72","57.7","","587.93","195.98","587.93","47","28.88","262.02","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","202.07","60.5","","245.05","205.73","411.45","20","28.88","262.02","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","202.07","60.5","","205.73","205.73","205.73","1 through 10","28.88","262.02","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.46","44.45","","249.86","148.07","249.86","1 through 10","28.88","262.02","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.02","78.45","","249.86","148.07","249.86","13","28.88","262.02","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","AETNA [1001]","HB CH AETNA HMO / PPO","2167.30","58.3","","464.71","67.87","1012.10","221","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2167.30","58.3","","293.04","293.04","293.04","11","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1970.28","53","","983.89","983.89","983.89","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2156.15","58","","677.18","677.18","677.18","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2323.44","62.5","","46.58","46.58","46.58","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2713.78","73","","747.15","747.15","747.15","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.43","44.45","","1141.67","481.21","1141.67","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.43","44.45","","76.54","76.54","76.54","1 through 10","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","WELLPOINT [1015]","HB CH WELLPOINT","2896.30","77.91","","273.64","94.28","1367.51","138","1652.43","2896.3","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2204.48","59.3","","720.78","230.14","2010.94","427","1858.75","2916.38","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2204.48","59.3","","344.45","344.45","344.45","1 through 10","1858.75","2916.38","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2916.38","78.45","","1120.13","1120.13","1120.13","1 through 10","1858.75","2916.38","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2916.38","78.45","","456.17","105.33","1284.66","242","1858.75","2916.38","percent of total billed charges",""
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","35658.30","26743.72","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14957.26","","Case rate ($14,521.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,917.63, add-ons for qualifying new technology services are included. If operating cost exceeds $60,059.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,051.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,411.88. The transfer operating threshold is the transfer adjustment factor * $14,917.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,109.73. The transfer capital threshold is the transfer adjustment factor * $1,109.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15272.49","15272.49","15272.49","1 through 10","14231.18","17205.17","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","35658.30","26743.72","MEDICARE [2001]","HB NWH MEDICARE","15966.87","","Case rate ($15,966.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,917.63, add-ons for qualifying new technology services are included. If operating cost exceeds $60,059.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,051.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,857.14. The transfer operating threshold is the transfer adjustment factor * $14,917.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,109.73. The transfer capital threshold is the transfer adjustment factor * $1,109.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14187.92","7087.51","16315.45","14","14231.18","17205.17","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","35658.30","26743.72","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14231.18","","Case rate ($14,521.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,917.63, add-ons for qualifying new technology services are included. If operating cost exceeds $60,059.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,051.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,411.88. The transfer operating threshold is the transfer adjustment factor * $14,917.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,109.73. The transfer capital threshold is the transfer adjustment factor * $1,109.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6332.17","6332.17","12652.37","1 through 10","14231.18","17205.17","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","35658.30","26743.72","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","14231.18","","Case rate ($14,521.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,917.63, add-ons for qualifying new technology services are included. If operating cost exceeds $60,059.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,051.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,411.88. The transfer operating threshold is the transfer adjustment factor * $14,917.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,109.73. The transfer capital threshold is the transfer adjustment factor * $1,109.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16920.49","16920.49","16920.49","1 through 10","14231.18","17205.17","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","35658.30","26743.72","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14231.18","","Case rate ($14,521.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,917.63, add-ons for qualifying new technology services are included. If operating cost exceeds $60,059.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,051.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,411.88. The transfer operating threshold is the transfer adjustment factor * $14,917.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,109.73. The transfer capital threshold is the transfer adjustment factor * $1,109.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14581.24","14581.24","14581.24","1 through 10","14231.18","17205.17","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","25708.03","19281.02","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8578.50","","Case rate ($8,328.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,555.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,698.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,578.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,692.17. The transfer operating threshold is the transfer adjustment factor * $8,555.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $636.47. The transfer capital threshold is the transfer adjustment factor * $636.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8662.73","8662.73","8662.73","1 through 10","8162.07","9867.74","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","25708.03","19281.02","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8328.64","","Case rate ($8,328.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,555.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,698.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,578.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,692.17. The transfer operating threshold is the transfer adjustment factor * $8,555.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $636.47. The transfer capital threshold is the transfer adjustment factor * $636.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8311.29","8311.29","8311.29","1 through 10","8162.07","9867.74","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","25708.03","19281.02","MEDICARE [2001]","HB NWH MEDICARE","8328.64","","Case rate ($8,328.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,555.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,698.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,578.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,692.17. The transfer operating threshold is the transfer adjustment factor * $8,555.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $636.47. The transfer capital threshold is the transfer adjustment factor * $636.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9198.66","6355.74","9215.20","77","8162.07","9867.74","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","25708.03","19281.02","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8162.07","","Case rate ($8,328.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,555.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,698.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,578.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,692.17. The transfer operating threshold is the transfer adjustment factor * $8,555.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $636.47. The transfer capital threshold is the transfer adjustment factor * $636.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8219.35","43.17","9173.18","1 through 10","8162.07","9867.74","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","25708.03","19281.02","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8162.07","","Case rate ($8,328.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,555.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,698.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,578.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,692.17. The transfer operating threshold is the transfer adjustment factor * $8,555.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $636.47. The transfer capital threshold is the transfer adjustment factor * $636.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8215.35","8215.35","8232.12","1 through 10","8162.07","9867.74","other","Inpatient DRG"
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","both","","","276.84","207.63","AETNA [1001]","HB CH AETNA HMO / PPO","161.40","58.3","","0.01","0.01","0.01","1 through 10","146.73","426.39","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","276.84","207.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.51","52.2","","0.01","0.01","0.01","1 through 10","0.01","167.49","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","276.84","207.63","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","159.74","57.7","","0.01","0.01","0.01","1 through 10","0.01","167.49","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","both","","","324.36","243.27","AETNA [1001]","HB CH AETNA HMO / PPO","189.10","58.3","","183.91","183.91","183.91","1 through 10","171.91","764.14","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","both","","","324.36","243.27","WELLPOINT [1015]","HB CH WELLPOINT","252.71","77.91","","255.47","255.47","255.47","1 through 10","171.91","764.14","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","324.36","243.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.46","78.45","","324.36","324.36","324.36","1 through 10","144.18","552.3","percent of total billed charges",""
"Menstrual And Other Female Reproductive System Disorders With Cc/McC","760","MS-DRG","","","","","","","","inpatient","","","15759.70","11819.77","MEDICARE [2001]","HB NWH MEDICARE","8728.89","","Case rate ($8,728.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,966.95, add-ons for qualifying new technology services are included. If operating cost exceeds $54,109.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,609.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,061.85. The transfer operating threshold is the transfer adjustment factor * $8,966.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.05. The transfer capital threshold is the transfer adjustment factor * $667.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6731.31","6731.31","9406.73","1 through 10","8554.31","9746.5984","other","Inpatient Replacement Plans DRG"
"Menstrual And Other Female Reproductive System Disorders,MINOR","532","DRG","","","","","","","","inpatient","","","17566.78","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11594.12","","Fee schedule rate ($11,594.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11594.12","11594.12","11594.12","1 through 10","2305","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","12239.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13119.60","","Standard inlier is a Case rate ($13,119.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,178, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,862.27) for the length of stay and the standard reimbursement.","1862.27","1862.27","1862.27","1 through 10","2305","35619.95","case rate",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","74.28","1 through 10","15.93","128.25","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.77","76.77","76.77","1 through 10","16.76","105.91","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","100.71","59.68","100.71","1 through 10","16.76","105.91","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","AETNA [1001]","HB CH AETNA HMO / PPO","385.23","58.3","","1862.60","353.13","2619.54","16","293.71","514.81","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","WELLPOINT [1015]","HB CH WELLPOINT","514.81","77.91","","2876.71","1548.58","2876.71","1 through 10","293.71","514.81","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","660.77","495.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.84","59.3","","1151.69","270.51","3652.50","14","330.39","518.37","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","660.77","495.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","518.37","78.45","","2808.04","1107.07","2808.04","12","330.39","518.37","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","666.86","500.14","AETNA [1001]","HB CH AETNA HMO / PPO","388.78","58.3","","1862.60","353.13","2619.54","16","296.42","519.55","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","666.86","500.14","WELLPOINT [1015]","HB CH WELLPOINT","519.55","77.91","","2876.71","1548.58","2876.71","1 through 10","296.42","519.55","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","666.86","500.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","395.45","59.3","","1151.69","270.51","3652.50","14","333.43","523.15","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","666.86","500.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.15","78.45","","2808.04","1107.07","2808.04","12","333.43","523.15","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","AETNA [1001]","HB CH AETNA HMO / PPO","504.41","58.3","","1862.60","353.13","2619.54","16","384.58","674.08","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","WELLPOINT [1015]","HB CH WELLPOINT","674.08","77.91","","2876.71","1548.58","2876.71","1 through 10","384.58","674.08","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","865.20","648.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","513.06","59.3","","1151.69","270.51","3652.50","14","432.6","678.75","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","865.20","648.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","678.75","78.45","","2808.04","1107.07","2808.04","12","432.6","678.75","percent of total billed charges",""
"MESH GRAFT 26CMX20MM PARIETEX COMPOSITE KNITTED PORCINE COLLAGEN POLYESTER 3D SKIRTED RECTANGLE","SUP-ITM-10041873","CDM","C1781","HCPCS","0278","RC","","","","both","","","3250.53","2437.90","AETNA [1001]","HB CH AETNA HMO / PPO","1895.06","58.3","","1862.60","353.13","2619.54","16","1444.86","2532.49","percent of total billed charges",""
"MESH GRAFT 26CMX20MM PARIETEX COMPOSITE KNITTED PORCINE COLLAGEN POLYESTER 3D SKIRTED RECTANGLE","SUP-ITM-10041873","CDM","C1781","HCPCS","0278","RC","","","","both","","","3250.53","2437.90","WELLPOINT [1015]","HB CH WELLPOINT","2532.49","77.91","","2876.71","1548.58","2876.71","1 through 10","1444.86","2532.49","percent of total billed charges",""
"MESH GRAFT 26CMX20MM PARIETEX COMPOSITE KNITTED PORCINE COLLAGEN POLYESTER 3D SKIRTED RECTANGLE","SUP-ITM-10041873","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3250.53","2437.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","1927.56","59.3","","1151.69","270.51","3652.50","14","1625.27","2550.04","percent of total billed charges",""
"MESH GRAFT 26CMX20MM PARIETEX COMPOSITE KNITTED PORCINE COLLAGEN POLYESTER 3D SKIRTED RECTANGLE","SUP-ITM-10041873","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3250.53","2437.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2550.04","78.45","","2808.04","1107.07","2808.04","12","1625.27","2550.04","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","3720.00","2790.00","AETNA [1001]","HB CH AETNA HMO / PPO","2168.76","58.3","","1862.60","353.13","2619.54","16","1653.54","2898.25","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","3720.00","2790.00","WELLPOINT [1015]","HB CH WELLPOINT","2898.25","77.91","","2876.71","1548.58","2876.71","1 through 10","1653.54","2898.25","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3720.00","2790.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2205.96","59.3","","1151.69","270.51","3652.50","14","1860","2918.34","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3720.00","2790.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2918.34","78.45","","2808.04","1107.07","2808.04","12","1860","2918.34","percent of total billed charges",""
"MESH GRAFT 5.0CMX10.0 1.0MM STENT GORE TEX PATCH SOFT TISSUE KEYHOLE","SUP-ITM-10076182","CDM","C1781","HCPCS","0278","RC","","","","both","","","714.00","535.50","AETNA [1001]","HB CH AETNA HMO / PPO","416.26","58.3","","1862.60","353.13","2619.54","16","317.37","556.28","percent of total billed charges",""
"MESH GRAFT 5.0CMX10.0 1.0MM STENT GORE TEX PATCH SOFT TISSUE KEYHOLE","SUP-ITM-10076182","CDM","C1781","HCPCS","0278","RC","","","","both","","","714.00","535.50","WELLPOINT [1015]","HB CH WELLPOINT","556.28","77.91","","2876.71","1548.58","2876.71","1 through 10","317.37","556.28","percent of total billed charges",""
"MESH GRAFT 5.0CMX10.0 1.0MM STENT GORE TEX PATCH SOFT TISSUE KEYHOLE","SUP-ITM-10076182","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","714.00","535.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","423.40","59.3","","1151.69","270.51","3652.50","14","357","560.13","percent of total billed charges",""
"MESH GRAFT 5.0CMX10.0 1.0MM STENT GORE TEX PATCH SOFT TISSUE KEYHOLE","SUP-ITM-10076182","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","714.00","535.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","560.13","78.45","","2808.04","1107.07","2808.04","12","357","560.13","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","3625.00","2718.75","AETNA [1001]","HB CH AETNA HMO / PPO","2113.38","58.3","","1862.60","353.13","2619.54","16","1611.31","2824.24","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","3625.00","2718.75","WELLPOINT [1015]","HB CH WELLPOINT","2824.24","77.91","","2876.71","1548.58","2876.71","1 through 10","1611.31","2824.24","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3625.00","2718.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.63","59.3","","1151.69","270.51","3652.50","14","1812.5","2843.81","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3625.00","2718.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.81","78.45","","2808.04","1107.07","2808.04","12","1812.5","2843.81","percent of total billed charges",""
"MESH MONOFILAMENT 20 XCM MARKING VERSATEX","SUP-ITM-10267156","CDM","C1781","HCPCS","0278","RC","","","","both","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","1862.60","353.13","2619.54","16","188.02","329.56","percent of total billed charges",""
"MESH MONOFILAMENT 20 XCM MARKING VERSATEX","SUP-ITM-10267156","CDM","C1781","HCPCS","0278","RC","","","","both","","","423.00","317.25","WELLPOINT [1015]","HB CH WELLPOINT","329.56","77.91","","2876.71","1548.58","2876.71","1 through 10","188.02","329.56","percent of total billed charges",""
"MESH MONOFILAMENT 20 XCM MARKING VERSATEX","SUP-ITM-10267156","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","1151.69","270.51","3652.50","14","211.5","331.84","percent of total billed charges",""
"MESH MONOFILAMENT 20 XCM MARKING VERSATEX","SUP-ITM-10267156","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.84","78.45","","2808.04","1107.07","2808.04","12","211.5","331.84","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","AETNA [1001]","HB CH AETNA HMO / PPO","1860.94","58.3","","1862.60","353.13","2619.54","16","1418.84","2486.89","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","WELLPOINT [1015]","HB CH WELLPOINT","2486.89","77.91","","2876.71","1548.58","2876.71","1 through 10","1418.84","2486.89","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3192.00","2394.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1892.86","59.3","","1151.69","270.51","3652.50","14","1596","2504.12","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3192.00","2394.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2504.12","78.45","","2808.04","1107.07","2808.04","12","1596","2504.12","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","AETNA [1001]","HB CH AETNA HMO / PPO","564.93","58.3","","1862.60","353.13","2619.54","16","430.72","754.95","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","WELLPOINT [1015]","HB CH WELLPOINT","754.95","77.91","","2876.71","1548.58","2876.71","1 through 10","430.72","754.95","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","969.00","726.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","574.62","59.3","","1151.69","270.51","3652.50","14","484.5","760.18","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","969.00","726.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","760.18","78.45","","2808.04","1107.07","2808.04","12","484.5","760.18","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","2190.90","412.50","9264.59","16","1066.8","1869.84","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","1903.20","1903.20","3826.66","1 through 10","1066.8","1869.84","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","2186.25","2186.25","2186.25","32","1066.8","1869.84","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","5556.60","5556.60","5556.60","1 through 10","1066.8","1869.84","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","1955.15","885.83","3150.40","26","1066.8","1869.84","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","831.03","253.22","2394.88","18","1200","1882.8","percent of total billed charges",""
"MESH SURGICAL 10X30MM 4 LOBE","SUP-ITM-10110187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","2481.69","1563.74","8149.28","1 through 10","1200","1882.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","AETNA [1001]","HB CH AETNA HMO / PPO","101.91","58.3","","1862.60","353.13","2619.54","16","77.7","136.19","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","WELLPOINT [1015]","HB CH WELLPOINT","136.19","77.91","","2876.71","1548.58","2876.71","1 through 10","77.7","136.19","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","174.80","131.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.66","59.3","","1151.69","270.51","3652.50","14","87.4","137.13","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","174.80","131.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.13","78.45","","2808.04","1107.07","2808.04","12","87.4","137.13","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","both","","","2674.59","2005.94","AETNA [1001]","HB CH AETNA HMO / PPO","1559.29","58.3","","416.75","416.75","416.75","1 through 10","1188.86","2083.77","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2674.59","2005.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","1586.03","59.3","","7893.60","423.68","7893.60","1 through 10","1337.3","2098.22","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2674.59","2005.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2098.22","78.45","","555.84","329.40","555.84","1 through 10","1337.3","2098.22","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","AETNA [1001]","HB CH AETNA HMO / PPO","233.72","58.3","","1862.60","353.13","2619.54","16","178.2","312.33","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","WELLPOINT [1015]","HB CH WELLPOINT","312.33","77.91","","2876.71","1548.58","2876.71","1 through 10","178.2","312.33","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.73","59.3","","1151.69","270.51","3652.50","14","200.45","314.5","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.50","78.45","","2808.04","1107.07","2808.04","12","200.45","314.5","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","AETNA [1001]","HB CH AETNA HMO / PPO","112.76","58.3","","1862.60","353.13","2619.54","16","85.98","150.69","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","WELLPOINT [1015]","HB CH WELLPOINT","150.69","77.91","","2876.71","1548.58","2876.71","1 through 10","85.98","150.69","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","193.42","145.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","114.70","59.3","","1151.69","270.51","3652.50","14","96.71","151.74","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","193.42","145.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","151.74","78.45","","2808.04","1107.07","2808.04","12","96.71","151.74","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","AETNA [1001]","HB CH AETNA HMO / PPO","651.21","58.3","","1862.60","353.13","2619.54","16","496.51","870.25","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","WELLPOINT [1015]","HB CH WELLPOINT","870.25","77.91","","2876.71","1548.58","2876.71","1 through 10","496.51","870.25","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1117.00","837.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.38","59.3","","1151.69","270.51","3652.50","14","558.5","876.29","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","876.29","78.45","","2808.04","1107.07","2808.04","12","558.5","876.29","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","AETNA [1001]","HB CH AETNA HMO / PPO","1970.67","58.3","","1862.60","353.13","2619.54","16","1502.51","2633.53","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","WELLPOINT [1015]","HB CH WELLPOINT","2633.53","77.91","","2876.71","1548.58","2876.71","1 through 10","1502.51","2633.53","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3380.22","2535.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","2004.47","59.3","","1151.69","270.51","3652.50","14","1690.11","2651.78","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3380.22","2535.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2651.78","78.45","","2808.04","1107.07","2808.04","12","1690.11","2651.78","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","AETNA [1001]","HB CH AETNA HMO / PPO","2465.45","58.3","","1862.60","353.13","2619.54","16","1879.75","3294.74","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","WELLPOINT [1015]","HB CH WELLPOINT","3294.74","77.91","","2876.71","1548.58","2876.71","1 through 10","1879.75","3294.74","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4228.90","3171.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.74","59.3","","1151.69","270.51","3652.50","14","2114.45","3317.57","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4228.90","3171.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3317.57","78.45","","2808.04","1107.07","2808.04","12","2114.45","3317.57","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.81","78.81","78.81","12","16.6","135.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","143.00","107.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","104.39","73","","101.47","101.47","101.47","1 through 10","16.6","135.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.45","81.45","87.12","1 through 10","17.47","112.18","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.86","63.33","278.00","1 through 10","17.47","112.18","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","AETNA [1001]","HB CH AETNA HMO / PPO","2574.04","58.3","","464.71","67.87","1012.10","221","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2574.04","58.3","","293.04","293.04","293.04","11","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2340.03","53","","983.89","983.89","983.89","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2560.79","58","","677.18","677.18","677.18","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2759.48","62.5","","46.58","46.58","46.58","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3223.07","73","","747.15","747.15","747.15","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.54","44.45","","1141.67","481.21","1141.67","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.54","44.45","","76.54","76.54","76.54","1 through 10","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.16","3311.37","WELLPOINT [1015]","HB CH WELLPOINT","3439.85","77.91","","273.64","94.28","1367.51","138","1962.54","3439.85","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.16","3311.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2618.19","59.3","","720.78","230.14","2010.94","427","2207.58","3463.69","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.16","3311.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2618.19","59.3","","344.45","344.45","344.45","1 through 10","2207.58","3463.69","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.16","3311.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3463.69","78.45","","1120.13","1120.13","1120.13","1 through 10","2207.58","3463.69","percent of total billed charges",""
"METAPHYSEAL PLATE 95MM 2HOLE AXSOS TITANIUM LOCKING PROXIMALIMAL LATERIAL LEFT","SUP-ITM-10034241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.16","3311.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3463.69","78.45","","456.17","105.33","1284.66","242","2207.58","3463.69","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","464.71","67.87","1012.10","221","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","293.04","293.04","293.04","11","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","983.89","983.89","983.89","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","677.18","677.18","677.18","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","46.58","46.58","46.58","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","747.15","747.15","747.15","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1141.67","481.21","1141.67","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","76.54","76.54","76.54","1 through 10","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","273.64","94.28","1367.51","138","1233.49","2162","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","720.78","230.14","2010.94","427","1387.5","2176.99","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1645.58","59.3","","344.45","344.45","344.45","1 through 10","1387.5","2176.99","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1387.5","2176.99","percent of total billed charges",""
"METATARSAL PLATE 2.4MM FIFTH HOOK","SUP-ITM-10154422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","456.17","105.33","1284.66","242","1387.5","2176.99","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","AETNA [1001]","HB CH AETNA HMO / PPO","2079.56","58.3","","464.71","67.87","1012.10","221","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2079.56","58.3","","293.04","293.04","293.04","11","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1890.51","53","","983.89","983.89","983.89","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2068.86","58","","677.18","677.18","677.18","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2229.38","62.5","","46.58","46.58","46.58","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.91","73","","747.15","747.15","747.15","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.53","44.45","","1141.67","481.21","1141.67","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.53","44.45","","76.54","76.54","76.54","1 through 10","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","WELLPOINT [1015]","HB CH WELLPOINT","2779.05","77.91","","273.64","94.28","1367.51","138","1585.53","2779.05","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2115.23","59.3","","720.78","230.14","2010.94","427","1783.5","2798.31","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2115.23","59.3","","344.45","344.45","344.45","1 through 10","1783.5","2798.31","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2798.31","78.45","","1120.13","1120.13","1120.13","1 through 10","1783.5","2798.31","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2798.31","78.45","","456.17","105.33","1284.66","242","1783.5","2798.31","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","464.71","67.87","1012.10","221","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","293.04","293.04","293.04","11","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","983.89","983.89","983.89","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","677.18","677.18","677.18","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","46.58","46.58","46.58","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","747.15","747.15","747.15","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1141.67","481.21","1141.67","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","76.54","76.54","76.54","1 through 10","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","273.64","94.28","1367.51","138","1066.8","1869.84","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","720.78","230.14","2010.94","427","1200","1882.8","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","344.45","344.45","344.45","1 through 10","1200","1882.8","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1120.13","1120.13","1120.13","1 through 10","1200","1882.8","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM BONE TITANIUM LOW PROFILE CONTOURED LT STANDARD","SUP-ITM-10115633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","456.17","105.33","1284.66","242","1200","1882.8","percent of total billed charges",""
"Methylene Blue Injection Non-Sentinel","PX-76002682","CDM","38999","CPT","0761","RC","","","","outpatient","","","520.00","390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","407.94","78.45","","389.01","389.01","389.01","1 through 10","255.16","970.06","percent of total billed charges",""
"Methylenedioxyamphetamines","PX-30002876","CDM","80359","CPT","0301","RC","","","","both","","","28.00","21.00","WELLPOINT [1015]","HB CH WELLPOINT","21.81","77.91","","148.37","148.37","148.37","1 through 10","14.84","445.13","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","101.65","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","44.72","44.72","44.72","1 through 10","9.6","83.94","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","23.63","147.25","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","265.47","88.49","265.47","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","67.80","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","99.00","74.25","AETNA [1001]","HB CH AETNA HMO / PPO","57.72","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","125.99","125.99","125.99","1 through 10","14.12","86.37","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","165.29","97.95","215.00","1 through 10","14.12","86.37","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","121.91","121.91","121.91","1 through 10","18.27","129.2","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","125.99","125.99","125.99","1 through 10","14.12","106.69","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","165.29","97.95","215.00","1 through 10","14.12","106.69","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","243.82","1 through 10","23.61","209.95","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","165.29","165.29","165.29","1 through 10","23.61","209.95","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","92.83","92.83","92.83","1 through 10","18.62","173.37","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","18.62","173.37","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","23.63","147.25","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","265.47","88.49","265.47","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","67.80","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","232","5.66","43.7","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","24.38","53","","47.70","47.70","47.70","1 through 10","5.66","43.7","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","33.58","73","","25.52","5.66","49.30","1 through 10","5.66","43.7","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","TRICARE [160005]","HB NWH TRICARE","43.70","95","","6.96","6.61","51.96","1 through 10","5.66","43.7","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.45","44.45","","20.50","20.50","34.60","1 through 10","5.66","43.7","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","26.37","225","5.57","36.09","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","46.00","34.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","27.28","59.3","","25.74","25.74","25.74","1 through 10","5.57","36.09","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","20.50","34.60","184","5.57","36.09","percent of total billed charges",""
"MICROCATHETER VASCULAR MICRO CANALOPLASTY ITRACK 250A RX ONLY","SUP-ITM-10240737","CDM","C1887","HCPCS","0272","RC","","","","both","","","3135.00","2351.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1661.55","53","","163.66","163.66","163.66","1 through 10","1393.51","2442.48","percent of total billed charges",""
"MICROCATHETER VASCULAR MICRO CANALOPLASTY ITRACK 250A RX ONLY","SUP-ITM-10240737","CDM","C1887","HCPCS","0272","RC","","","","both","","","3135.00","2351.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1959.38","62.5","","97.92","97.92","225.72","1 through 10","1393.51","2442.48","percent of total billed charges",""
"MICROCATHETER VASCULAR MICRO CANALOPLASTY ITRACK 250A RX ONLY","SUP-ITM-10240737","CDM","C1887","HCPCS","0272","RC","","","","both","","","3135.00","2351.25","WELLPOINT [1015]","HB CH WELLPOINT","2442.48","77.91","","243.20","243.20","243.20","1 through 10","1393.51","2442.48","percent of total billed charges",""
"MICROCATHETER VASCULAR MICRO CANALOPLASTY ITRACK 250A RX ONLY","SUP-ITM-10240737","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3135.00","2351.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2459.41","78.45","","40.36","40.36","40.36","1 through 10","1567.5","2459.41","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","55","14.26","113.05","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","119.00","89.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","86.87","73","","65.77","65.77","65.77","1 through 10","14.26","113.05","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","119.00","89.25","TRICARE [160005]","HB NWH TRICARE","113.05","95","","17.53","17.53","17.53","1 through 10","14.26","113.05","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.90","44.45","","89.18","89.18","89.18","1 through 10","14.26","113.05","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","67.98","116.00","37","15.01","93.36","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","89.18","52.85","89.18","26","15.01","93.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","AETNA [1001]","HB CH AETNA HMO / PPO","1169.36","58.3","","464.71","67.87","1012.10","221","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1169.36","58.3","","293.04","293.04","293.04","11","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1063.06","53","","983.89","983.89","983.89","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1163.35","58","","677.18","677.18","677.18","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1253.61","62.5","","46.58","46.58","46.58","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1464.21","73","","747.15","747.15","747.15","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","891.56","44.45","","1141.67","481.21","1141.67","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","891.56","44.45","","76.54","76.54","76.54","1 through 10","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.77","1504.33","WELLPOINT [1015]","HB CH WELLPOINT","1562.70","77.91","","273.64","94.28","1367.51","138","891.56","1562.7","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.77","1504.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1189.42","59.3","","720.78","230.14","2010.94","427","1002.89","1573.53","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.77","1504.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1189.42","59.3","","344.45","344.45","344.45","1 through 10","1002.89","1573.53","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.77","1504.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1573.53","78.45","","1120.13","1120.13","1120.13","1 through 10","1002.89","1573.53","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.77","1504.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1573.53","78.45","","456.17","105.33","1284.66","242","1002.89","1573.53","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","AETNA [1001]","HB CH AETNA HMO / PPO","1208.19","58.3","","464.71","67.87","1012.10","221","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1208.19","58.3","","293.04","293.04","293.04","11","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1098.36","53","","983.89","983.89","983.89","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1201.97","58","","677.18","677.18","677.18","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1295.23","62.5","","46.58","46.58","46.58","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1512.83","73","","747.15","747.15","747.15","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","921.17","44.45","","1141.67","481.21","1141.67","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","921.17","44.45","","76.54","76.54","76.54","1 through 10","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2072.37","1554.28","WELLPOINT [1015]","HB CH WELLPOINT","1614.58","77.91","","273.64","94.28","1367.51","138","921.17","1614.58","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2072.37","1554.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","1228.92","59.3","","720.78","230.14","2010.94","427","1036.19","1625.77","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2072.37","1554.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1228.92","59.3","","344.45","344.45","344.45","1 through 10","1036.19","1625.77","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2072.37","1554.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1625.77","78.45","","1120.13","1120.13","1120.13","1 through 10","1036.19","1625.77","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2072.37","1554.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1625.77","78.45","","456.17","105.33","1284.66","242","1036.19","1625.77","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","AETNA [1001]","HB CH AETNA HMO / PPO","2228.23","58.3","","464.71","67.87","1012.10","221","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2228.23","58.3","","293.04","293.04","293.04","11","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2025.66","53","","983.89","983.89","983.89","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2216.76","58","","677.18","677.18","677.18","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2388.75","62.5","","46.58","46.58","46.58","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2790.06","73","","747.15","747.15","747.15","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.88","44.45","","1141.67","481.21","1141.67","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.88","44.45","","76.54","76.54","76.54","1 through 10","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.00","2866.50","WELLPOINT [1015]","HB CH WELLPOINT","2977.72","77.91","","273.64","94.28","1367.51","138","1698.88","2977.72","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.00","2866.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2266.45","59.3","","720.78","230.14","2010.94","427","1911","2998.36","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.00","2866.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2266.45","59.3","","344.45","344.45","344.45","1 through 10","1911","2998.36","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.00","2866.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2998.36","78.45","","1120.13","1120.13","1120.13","1 through 10","1911","2998.36","percent of total billed charges",""
"MIDSHAFT PLATE 65MM 3 HOLE BONE CLAVICLE LOCKING SUPERIOR TITANIUM LOW PROFILE OLECRANON LEFT","SUP-ITM-10088526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.00","2866.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2998.36","78.45","","456.17","105.33","1284.66","242","1911","2998.36","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","AETNA [1001]","HB CH AETNA HMO / PPO","2398.33","58.3","","464.71","67.87","1012.10","221","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2398.33","58.3","","293.04","293.04","293.04","11","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.30","53","","983.89","983.89","983.89","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2385.99","58","","677.18","677.18","677.18","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2571.11","62.5","","46.58","46.58","46.58","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.06","73","","747.15","747.15","747.15","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.58","44.45","","1141.67","481.21","1141.67","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.58","44.45","","76.54","76.54","76.54","1 through 10","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.78","3085.33","WELLPOINT [1015]","HB CH WELLPOINT","3205.05","77.91","","273.64","94.28","1367.51","138","1828.58","3205.05","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","2439.47","59.3","","720.78","230.14","2010.94","427","2056.89","3227.26","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2439.47","59.3","","344.45","344.45","344.45","1 through 10","2056.89","3227.26","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3227.26","78.45","","1120.13","1120.13","1120.13","1 through 10","2056.89","3227.26","percent of total billed charges",""
"MIDSHAFT PLATE 88MM 7 HOLE BONE VARIAX TITANIUM SUPERIOR RIGHT","SUP-ITM-10126276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.78","3085.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3227.26","78.45","","456.17","105.33","1284.66","242","2056.89","3227.26","percent of total billed charges",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","37637.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21206.77","","Standard inlier is a Case rate ($21,206.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,900, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,010.21) for the length of stay and the standard reimbursement.","21206.77","21206.77","21206.77","1 through 10","4391.25","21206.77","case rate",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","37637.45","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19946.83","","Fee schedule rate ($19,946.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19946.83","19946.83","19946.83","1 through 10","4391.25","21206.77","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","39609.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17038.10","","Standard inlier is a Case rate ($17,038.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,418.49) for the length of stay and the standard reimbursement.","16263.64","16263.64","16263.64","1 through 10","4391.25","21206.77","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","39609.96","","MASSHEALTH [3001]","HB NWH MEDICAID","6038.55","","Case rate ($6,505.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,935.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28315.24","28315.24","28315.24","1 through 10","4391.25","21206.77","case rate",""
"Minor Bladder Procedures With McC","662","MS-DRG","","","","","","","","inpatient","","","43350.53","32512.90","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","25994.12","","Case rate ($26,524.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $27,247.98, add-ons for qualifying new technology services are included. If operating cost exceeds $72,390.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,968.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $24,497.63. The transfer operating threshold is the transfer adjustment factor * $27,247.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,026.98. The transfer capital threshold is the transfer adjustment factor * $2,026.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26599.30","26599.30","26599.30","1 through 10","25994.12","30849.7244","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","23429.18","17571.88","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14415.04","","Case rate ($14,415.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,467.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,610.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,943.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,413.18. The transfer operating threshold is the transfer adjustment factor * $13,467.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.87. The transfer capital threshold is the transfer adjustment factor * $1,001.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13886.38","13886.38","13886.38","1 through 10","12848.04","15533","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","23429.18","17571.88","MEDICARE [2001]","HB NWH MEDICARE","14415.04","","Case rate ($14,415.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,467.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,610.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,943.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,413.18. The transfer operating threshold is the transfer adjustment factor * $13,467.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.87. The transfer capital threshold is the transfer adjustment factor * $1,001.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15396.61","15368.98","15396.61","1 through 10","12848.04","15533","other","Inpatient DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","23449.09","17586.82","MEDICARE [2001]","HB NWH MEDICARE","7852.99","","Case rate ($7,852.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,067.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,209.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,542.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,252.87. The transfer operating threshold is the transfer adjustment factor * $8,067.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $600.12. The transfer capital threshold is the transfer adjustment factor * $600.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8248.08","8248.08","8262.91","1 through 10","7695.93","8546.0738","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","31183.41","23387.56","MEDICARE [2001]","HB NWH MEDICARE","14334.07","","Case rate ($14,334.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,392.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,534.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,938.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,337.83. The transfer operating threshold is the transfer adjustment factor * $13,392.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.24. The transfer capital threshold is the transfer adjustment factor * $996.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14233.94","14233.94","14233.94","1 through 10","12775.87","14721.7543","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","31183.41","23387.56","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12775.87","","Case rate ($13,036.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,392.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,534.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,938.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,040.37. The transfer operating threshold is the transfer adjustment factor * $13,392.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.24. The transfer capital threshold is the transfer adjustment factor * $996.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12693.41","12693.41","12693.41","1 through 10","12775.87","14721.7543","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11918.70","","Case rate ($11,571.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,887.12, add-ons for qualifying new technology services are included. If operating cost exceeds $57,029.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,826.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,687.25. The transfer operating threshold is the transfer adjustment factor * $11,887.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.29. The transfer capital threshold is the transfer adjustment factor * $884.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11889.36","11889.36","11889.36","1 through 10","11340.12","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12723.21","","Case rate ($12,723.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,887.12, add-ons for qualifying new technology services are included. If operating cost exceeds $57,029.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,826.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,838.91. The transfer operating threshold is the transfer adjustment factor * $11,887.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.29. The transfer capital threshold is the transfer adjustment factor * $884.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11455.40","11455.40","11455.40","1 through 10","11340.12","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8577.96","8577.96","8577.96","1 through 10","11340.12","13709.93","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","MEDICARE [2001]","HB NWH MEDICARE","12723.21","","Case rate ($12,723.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,887.12, add-ons for qualifying new technology services are included. If operating cost exceeds $57,029.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,826.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,838.91. The transfer operating threshold is the transfer adjustment factor * $11,887.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.29. The transfer capital threshold is the transfer adjustment factor * $884.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12674.67","7041.95","12697.44","58","11340.12","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11340.12","","Case rate ($11,571.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,887.12, add-ons for qualifying new technology services are included. If operating cost exceeds $57,029.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,826.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,687.25. The transfer operating threshold is the transfer adjustment factor * $11,887.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.29. The transfer capital threshold is the transfer adjustment factor * $884.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11323.20","11323.20","11323.20","1 through 10","11340.12","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","28215.14","21161.35","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","11340.12","","Case rate ($11,571.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,887.12, add-ons for qualifying new technology services are included. If operating cost exceeds $57,029.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,826.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,687.25. The transfer operating threshold is the transfer adjustment factor * $11,887.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.29. The transfer capital threshold is the transfer adjustment factor * $884.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11350.81","11321.29","11356.72","1 through 10","11340.12","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7413.29","","Case rate ($7,413.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,898.05. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6740.40","6740.40","6740.40","1 through 10","6607.42","7727.2646","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","HUMANA [1012]","HB NWH MEDICARE","7413.29","","Case rate ($7,413.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,898.05. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6660.49","6660.49","6660.49","1 through 10","6607.42","7727.2646","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","MEDICARE [2001]","HB NWH MEDICARE","7413.29","","Case rate ($7,413.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,898.05. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7457.81","934.96","7471.21","49","6607.42","7727.2646","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6607.42","","Case rate ($6,742.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,227.03. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6670.21","6662.61","6693.01","1 through 10","6607.42","7727.2646","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6607.42","","Case rate ($6,742.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,227.03. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32.48","32.48","32.48","1 through 10","6607.42","7727.2646","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","17525.12","13143.84","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6607.42","","Case rate ($6,742.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,926.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,068.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,457.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,227.03. The transfer operating threshold is the transfer adjustment factor * $6,926.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $515.24. The transfer capital threshold is the transfer adjustment factor * $515.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6678.41","5131.23","7546.84","1 through 10","6607.42","7727.2646","other","Inpatient DRG"
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB CH AETNA HMO / PPO","123.60","58.3","","116.80","116.80","116.80","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","152.85","72.1","","155.32","155.32","155.32","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","134.41","63.4","","136.58","136.58","136.58","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.23","44.45","","93.85","93.85","93.85","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","WELLPOINT [1015]","HB CH WELLPOINT","165.17","77.91","","162.25","162.25","162.25","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.72","59.3","","120.72","120.72","120.72","12","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","122.32","57.7","","124.22","119.48","237.52","22","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","128.26","60.5","","130.40","130.40","136.58","1 through 10","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","166.31","78.45","","158.37","93.85","158.37","1 through 10","63.83","166.31","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","both","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.11","44.45","","25.37","15.03","25.37","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","19.34","1 through 10","17","26.67","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","15.03","25.37","1 through 10","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","53","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","24.82","73","","22.63","22.63","22.63","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.82","73","","34.96","17.48","37.42","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.11","44.45","","25.37","15.03","25.37","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","WELLPOINT [1015]","HB CH WELLPOINT","26.49","77.91","","25.99","25.99","51.98","12","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","58.02","27","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","15.03","25.37","20","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","15","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","24.82","73","","22.63","22.63","22.63","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.82","73","","17.48","17.48","18.71","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","WELLPOINT [1015]","HB CH WELLPOINT","26.49","77.91","","25.99","25.99","51.98","1 through 10","15.11","26.49","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","19.34","1 through 10","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","25.37","25.37","1 through 10","17","26.67","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","58421.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","53830.04","","Standard inlier is a Case rate ($53,830.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $66,870, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,641.38) for the length of stay and the standard reimbursement.","30927.96","30927.96","30927.96","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","58421.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","57824.20","","Standard inlier is a Case rate ($57,824.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $66,870, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,207.90) for the length of stay and the standard reimbursement.","1727.06","1727.06","1727.06","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","58421.81","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","33348.423","","Fee schedule rate ($57,009.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33348.423","57009.88","57009.88","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","951","DRG","","","","","","","","inpatient","","","26810.09","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","20851.12","","Fee schedule rate ($20,851.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20851.12","20851.12","20851.12","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","36524.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38468.71","","Standard inlier is a Case rate ($38,468.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,386, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,460.47) for the length of stay and the standard reimbursement.","17535.81","17535.81","17535.81","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","36524.02","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","35015.6735","","Fee schedule rate ($31,562.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35015.6735","59333.61","59333.61","1 through 10","5007.84","94065.42","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","36524.02","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37237.65","","Fee schedule rate ($37,237.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37237.65","37237.65","37237.65","1 through 10","5007.84","94065.42","case rate",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","65.64","65.64","65.64","1 through 10","36.63","97","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","inpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.01","70.6","","45.10","45.10","45.10","1 through 10","57.12","72.01","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","58.01","58.01","58.01","1 through 10","29.85","80.02","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","AETNA [1001]","HB CH AETNA HMO / PPO","1061.64","58.3","","1004.16","1004.16","1004.16","1 through 10","269.33","1729.95","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","both","","","1821.00","1365.75","WELLPOINT [1015]","HB CH WELLPOINT","1418.74","77.91","","1394.84","1394.84","1394.84","1 through 10","269.33","1729.95","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1079.85","59.3","","1037.81","1037.81","1037.81","1 through 10","809.43","1428.57","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","outpatient","","","1821.00","1365.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1428.57","78.45","","1361.55","1361.55","1361.55","1 through 10","809.43","1428.57","percent of total billed charges",""
"Molecular Path Procedure Level 6","PX-31000007","CDM","81405","CPT","0310","RC","","","","outpatient","","","3651.00","2738.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2165.04","59.3","","2080.30","2080.30","2080.30","1 through 10","970.35","2864.21","percent of total billed charges",""
"Molecular Path Procedure Level 6","PX-31000007","CDM","81405","CPT","0310","RC","","","","outpatient","","","3651.00","2738.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2864.21","78.45","","2729.24","2729.24","2729.24","1 through 10","970.35","2864.21","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","1 through 10","26.24","157.97","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","59.19","59.19","59.19","1 through 10","11.33","100.56","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","77.65","77.65","1 through 10","11.33","100.56","percent of total billed charges",""
"MORCELLATOR ROTATION 4 75MM WL 335 3 PIECES O CONSISTING OF OUTER INNER BLADE FOR SPECIAL APPLICATION PK/3EA","SUP-ITM-10181278","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1051.43","788.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","623.50","59.3","","1002.06","1002.06","1002.06","1 through 10","467.36","824.85","percent of total billed charges",""
"MORCELLATOR ROTATION 4 75MM WL 335 3 PIECES O CONSISTING OF OUTER INNER BLADE FOR SPECIAL APPLICATION PK/3EA","SUP-ITM-10181278","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1051.43","788.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","824.85","78.45","","1026.35","1026.35","1026.35","1 through 10","467.36","824.85","percent of total billed charges",""
"Morcellator T1","PX-27000122","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1181.25","885.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.48","59.3","","1002.06","1002.06","1002.06","1 through 10","525.07","926.69","percent of total billed charges",""
"Morcellator T1","PX-27000122","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1181.25","885.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","926.69","78.45","","1026.35","1026.35","1026.35","1 through 10","525.07","926.69","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","AETNA [1001]","HB CH AETNA HMO / PPO","511.87","58.3","","484.22","484.22","484.22","1 through 10","390.27","1456.11","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","WELLPOINT [1015]","HB CH WELLPOINT","684.05","77.91","","1526.61","628.63","1526.61","1 through 10","390.27","1456.11","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","520.65","59.3","","500.44","500.44","500.44","1 through 10","324.26","926.86","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","688.79","78.45","","656.56","656.56","656.56","1 through 10","324.26","926.86","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1159.00","869.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","598.61","1771","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1159.00","869.25","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","1890.36","33","598.61","1771","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1159.00","869.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","573.68","617.92","1 through 10","598.61","1771","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1159.00","869.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","630.12","630.12","630.12","1 through 10","598.61","1771","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1159.00","869.25","WELLPOINT [1015]","HB CH WELLPOINT","902.98","77.91","","887.63","887.63","887.63","1 through 10","598.61","1771","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","1159.00","869.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","687.29","59.3","","660.42","660.42","660.42","1 through 10","515.18","1293.36","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","1159.00","869.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","909.24","78.45","","866.44","866.44","866.44","1 through 10","515.18","1293.36","percent of total billed charges",""
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","952.43","1015.16","19","385.88","3798.11","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","999.86","999.86","999.86","1 through 10","385.88","3798.11","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","998.92","997.86","998.92","1 through 10","385.88","3798.11","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1732.58","35.54","","1650.94","1650.94","1650.94","1 through 10","385.88","1881.54","percent of total billed charges",""
"Mra Abdomen W/O Contrast","PX-61000102","CDM","C8901","HCPCS","0618","RC","","","","both","","","3041.00","2280.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","641.60","598.75","641.60","1 through 10","272.7","2369.24","other","OPPS APC"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","484.28","484.28","484.28","1 through 10","292.92","3848.45","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","2349.58","58","","811.30","811.30","811.30","1 through 10","292.92","3848.45","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2349.58","58","","954.47","954.47","954.47","1 through 10","292.92","3848.45","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2531.88","62.5","","1021.34","1021.34","1021.34","1 through 10","292.92","3848.45","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","WELLPOINT [1015]","HB CH WELLPOINT","3156.13","77.91","","3733.22","3733.22","3733.22","1 through 10","292.92","3848.45","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1459.45","","Case rate ($1,459.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1459.45","1221.26","1459.45","1 through 10","385.88","2025.5","other","Multiple Imaging"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1459.45","","Case rate ($1,459.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1459.45","1221.26","1459.45","11","385.88","2025.5","other","Multiple Imaging"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","1 through 10","385.88","2025.5","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","1099.76","1 through 10","385.88","2025.5","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","2025.5","other","Multiple Radiology"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","4992.00","3744.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","848.22","1 through 10","385.88","3889.27","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","4992.00","3744.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","418.43","418.43","1 through 10","385.88","3889.27","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","outpatient","","","4992.00","3744.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1774.16","35.54","","1690.65","1690.65","1690.65","1 through 10","385.88","2496","percent of total billed charges",""
"Mra Head W&W/O Cont","PX-61000083","CDM","70546","CPT","0615","RC","","","","both","","","6118.00","4588.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","951.85","951.85","951.85","1 through 10","385.88","4466.14","other","Multiple Radiology"
"Mra Head W&W/O Cont","PX-61000083","CDM","70546","CPT","0615","RC","","","","both","","","6118.00","4588.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","385.88","4466.14","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","2985.7","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","641.60","287.06","1015.16","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","662.40","662.40","662.40","1 through 10","225.91","2985.7","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","284.32","286.32","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2254.96","2254.96","2254.96","1 through 10","230.56","2045","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","584.01","1 through 10","230.56","2045","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","348.96","697.91","13","230.56","2045","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","262.84","525.68","1 through 10","230.56","2045","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","265.14","265.14","265.14","1 through 10","230.56","2045","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1453.59","35.54","","1811.92","1811.92","1811.92","1 through 10","230.56","2045","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","937.19","998.92","1 through 10","385.88","4508.48","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","4508.48","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","837.06","837.06","837.06","1 through 10","385.88","4508.48","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1085.20","1085.20","1085.20","1 through 10","385.88","4508.48","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","6249.89","6249.89","6249.89","1 through 10","385.88","3088","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","3088","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","977.44","1168.07","13","385.88","3088","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","4399.05","439.90","4399.05","1 through 10","385.88","3088","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2194.95","35.54","","2091.54","2091.54","4426.96","1 through 10","385.88","3088","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","998.92","998.92","1 through 10","265.02","3111.99","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","848.22","848.22","1 through 10","265.02","3111.99","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","563.44","563.44","563.44","1 through 10","265.02","3111.99","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","662.87","662.87","662.87","1 through 10","265.02","3111.99","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","730.47","730.47","730.47","1 through 10","265.02","3111.99","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","584.04","977.44","1 through 10","385.88","2131.5","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","1168.07","1 through 10","385.88","2131.5","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","1 through 10","385.88","2131.5","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","2131.5","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1515.07","35.54","","1443.70","1443.70","1443.70","1 through 10","385.88","2131.5","percent of total billed charges",""
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4097.00","3072.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","2048.5","other","Multiple Imaging"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4097.00","3072.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2048.5","other","Multiple Radiology"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4097.00","3072.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1456.07","35.54","","1387.63","1387.63","1387.63","1 through 10","230.56","2048.5","percent of total billed charges",""
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","both","","","4974.00","3730.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","998.92","998.92","1 through 10","385.88","3875.24","other","OPPS APC"
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","both","","","4974.00","3730.50","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","3875.24","other","OPPS APC"
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","outpatient","","","4974.00","3730.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1767.76","35.54","","1684.73","1684.73","1684.73","1 through 10","385.88","2487","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","33","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","ELDER SERVICES [1037]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","411.34","411.34","411.34","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","FALLON HEALTH [1008]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.33","1272.33","1272.33","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","1450.91","1450.91","1450.91","1 through 10","385.88","4079.24","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","549.88","1099.76","1 through 10","385.88","4079.24","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","484.28","968.56","20","385.88","4079.24","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.97","415.97","415.97","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","493","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","755.98","755.98","755.98","1 through 10","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","889.38","889.38","889.38","20","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","889.38","880.31","933.85","1 through 10","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","980.08","980.08","980.08","46","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","385.88","4079.24","other","Tricare OPPS"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","420.63","64","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","572.55","572.55","572.55","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1985.98","35.54","","2475.73","2475.73","2475.73","1 through 10","385.88","4079.24","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","415.63","420.63","31","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3081.08","3081.08","3081.08","1 through 10","385.88","2794","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.04","1168.07","99","385.88","2794","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","584.04","977.44","1 through 10","385.88","2794","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.04","1168.07","241","385.88","2794","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","86","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","887.52","1099.76","43","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1985.98","35.54","","1892.66","1892.66","2475.73","23","385.88","2794","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","1629.83","1629.83","1629.83","1 through 10","230.56","2578.36","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","19","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","284.12","284.12","1 through 10","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","265.90","284.32","1 through 10","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","584.01","1 through 10","230.56","1766","other","Multiple Imaging"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","348.96","697.91","1 through 10","230.56","1766","other","Multiple Imaging"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","1766","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","1766","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1255.27","35.54","","1564.53","1564.53","1564.53","1 through 10","230.56","1766","percent of total billed charges",""
"MRI Abdomen W/O Cont|REDUCED SERVICES","PX-61000065","CDM","74181","CPT","0614","RC","","","52","both","","","3532.00","2649.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","133.72","133.72","133.72","1 through 10","272.7","295.64","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","998.92","28","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","FALLON HEALTH [1008]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.33","1272.33","1272.33","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","4006.24","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","935.59","968.56","15","385.88","4006.24","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4006.24","73","","3895.28","3895.28","3895.28","1 through 10","385.88","4006.24","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","370","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","679.77","679.77","679.77","1 through 10","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","799.73","776.58","1206.36","18","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","839.72","799.73","839.72","1 through 10","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","881.28","855.77","881.28","53","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1015.16","402.90","1015.16","1 through 10","385.88","4006.24","other","Tricare OPPS"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","420.63","51","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.44","35.54","","2431.08","2431.08","2431.08","1 through 10","385.88","4006.24","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.03","415.63","420.63","30","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3025.51","3025.51","3025.51","1 through 10","385.88","2744","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","113","385.88","2744","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","1168.07","1168.07","1 through 10","385.88","2744","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","255","385.88","2744","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","94","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","968.56","29","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1950.44","35.54","","1858.53","1858.53","2431.08","37","385.88","2744","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","4620.00","3465.00","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","3372.6","other","OPPS APC"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","4620.00","3465.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","706.47","706.47","706.47","1 through 10","385.88","3372.6","other","Multiple Imaging"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","4620.00","3465.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","2310","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0610","RC","","","","inpatient","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2974.38","70.6","","1866.59","1866.59","1866.59","1 through 10","2359.28","2974.38","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","17","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","866.91","866.91","866.91","1 through 10","225.91","3075.49","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","3075.49","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","HUMANA [1012]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","286.22","283.32","286.22","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH QHM INTERNATIONAL","2527.80","60","","2458.20","2458.20","2458.20","1 through 10","225.91","3075.49","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","297","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","408.22","408.22","408.22","1 through 10","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","480.26","466.36","480.26","14","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","504.27","504.27","504.27","1 through 10","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","529.23","529.23","529.23","43","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3075.49","73","","2990.81","2990.81","2990.81","1 through 10","225.91","3075.49","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","281.32","997.66","33","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1497.30","35.54","","1426.99","1426.99","1426.99","1 through 10","225.91","3075.49","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","263.16","286.32","34","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2323.00","2323.00","2323.00","1 through 10","230.56","2106.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","697.91","51","230.56","2106.5","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","128","230.56","2106.5","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","2628.40","47","230.56","2106.5","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","578.71","16","230.56","2106.5","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","2106.5","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1497.30","35.54","","1426.99","1426.99","3021.83","35","230.56","2106.5","percent of total billed charges",""
"MRI Brain W/O Cont|REDUCED SERVICES","PX-61000016","CDM","70551","CPT","0611","RC","","","52","both","","","4213.00","3159.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","295.64","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","142","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","385.88","6110.48","other","Tricare OPPS"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","414.14","418.43","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.13","414.64","424.11","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","AETNA [1001]","HB CH AETNA HMO / PPO","2743.02","58.3","","2594.03","2594.03","2594.03","1 through 10","230.56","3665.67","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","295.64","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","298.38","298.38","298.38","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","230.56","3665.67","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","281.32","286.32","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2352.5","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2352.5","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2352.5","other","Multiple Radiology"
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","both","","","4688.00","3516.00","AETNA [1001]","HB CH AETNA HMO / PPO","2733.10","58.3","","2584.95","2584.95","2584.95","1 through 10","230.56","3652.42","percent of total billed charges",""
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","outpatient","","","4688.00","3516.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2344","other","Multiple Radiology"
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","both","","","2013.00","1509.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","947.39","947.39","947.39","1 through 10","274.43","1912.35","other","Multiple Radiology"
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2013.00","1509.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1388.06","","Case rate ($1,388.06). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1388.06","1388.06","1388.06","1 through 10","385.88","3226.45","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","AETNA [1001]","HB CH AETNA HMO / PPO","1167.75","58.3","","4418.63","4418.63","4418.63","78","271.02","1902.85","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","1450.91","1450.91","1450.91","1 through 10","271.02","1902.85","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1450.91","1 through 10","271.02","1902.85","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","929.97","968.56","50","271.02","1902.85","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","WELLPOINT [1015]","HB CH WELLPOINT","1560.54","77.91","","6137.77","6137.77","6137.77","24","271.02","1902.85","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1155.83","1381.26","181","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1381.26","1381.26","1 through 10","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1155.83","1381.26","461","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","173","385.88","4377.06","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","1099.76","62","385.88","4377.06","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","4377.06","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","711.87","35.54","","2714.30","2714.30","2714.30","1 through 10","385.88","4377.06","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","628.54","31.38","","3550.49","3550.49","3550.49","1 through 10","385.88","4377.06","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.87","35.54","","2714.30","2714.30","3550.49","65","385.88","4377.06","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","484.28","968.56","1 through 10","385.88","3949.3","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1863.38","22","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","886.64","860.97","886.64","1 through 10","385.88","3949.3","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","997.66","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","999.06","418.63","999.06","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","1168.07","1 through 10","385.88","2705","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","1168.07","29","385.88","2705","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","1319.70","1 through 10","385.88","2705","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","1775.04","461.13","1775.04","1 through 10","385.88","2705","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1922.71","35.54","","2396.91","1832.41","2396.91","1 through 10","385.88","2705","percent of total billed charges",""
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","both","","","4662.00","3496.50","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","1015.16","1015.16","1 through 10","385.88","3403.26","other","OPPS APC"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","4662.00","3496.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","977.44","977.44","1 through 10","385.88","2331","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","2737.5","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","96","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","390.73","390.73","390.73","1 through 10","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","459.68","459.68","459.68","1 through 10","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","506.55","506.55","506.55","16","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1886.31","284.12","1890.81","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.32","631.77","14","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","32","230.56","1875","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","60","230.56","1875","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","504.93","525.68","21","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","1102.08","13","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","530.29","530.29","530.29","1 through 10","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1332.75","35.54","","1269.90","1269.90","1661.12","1 through 10","230.56","1875","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","385.88","3301.79","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","941.86","1099.76","1 through 10","385.88","3301.79","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","21","385.88","3301.79","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","385.88","3301.79","other","Tricare OPPS"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.43","420.63","1 through 10","385.88","3301.79","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4523.00","3392.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.33","416.13","420.63","1 through 10","385.88","3301.79","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4523.00","3392.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","2261.5","other","Multiple Imaging"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4523.00","3392.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","2261.5","other","Multiple Imaging"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4523.00","3392.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","2261.5","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4523.00","3392.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1607.47","35.54","","1531.82","1531.82","2003.73","1 through 10","385.88","2261.5","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","385.88","4788.07","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","4788.07","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1377.21","1377.21","1377.21","1 through 10","385.88","4788.07","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1517.65","1517.65","1517.65","1 through 10","385.88","4788.07","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","417.32","1 through 10","385.88","4788.07","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3616.33","3616.33","3616.33","1 through 10","385.88","3279.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","3279.5","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","1168.07","1168.07","1 through 10","385.88","3279.5","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","3279.5","other","Multiple Radiology"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","461.13","1 through 10","385.88","3279.5","other","Multiple Radiology"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","4735.00","3551.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","3456.55","other","Multiple Radiology"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","4735.00","3551.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","225.91","3456.55","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","4735.00","3551.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2367.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","925.68","968.56","1 through 10","385.88","3893.09","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","21","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","681.84","681.84","681.84","1 through 10","385.88","3893.09","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","793.98","793.98","793.98","1 through 10","385.88","3893.09","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","883.96","883.96","883.96","1 through 10","385.88","3893.09","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.13","413.34","417.13","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","411.34","411.34","415.63","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","2666.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","488.72","1168.07","15","385.88","2666.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","1 through 10","385.88","2666.5","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","2666.5","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1895.35","35.54","","2362.74","1806.28","2362.74","1 through 10","385.88","2666.5","percent of total billed charges",""
"MRI L-Spine W/Cont","PX-61000029","CDM","72149","CPT","0612","RC","","","","outpatient","","","4575.00","3431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","488.72","488.72","488.72","1 through 10","385.88","2287.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","19","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","225.91","2717.79","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","1265.16","1 through 10","225.91","2717.79","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","230","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","460.89","460.89","460.89","1 through 10","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.94","460.89","483.94","1 through 10","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","507.89","493.19","507.89","38","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","TRICARE [160005]","HB NWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","272.71","287.06","1 through 10","225.91","2717.79","other","Tricare OPPS"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","267.09","286.32","28","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","265.90","286.32","20","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2052.54","2052.54","2052.54","1 through 10","230.56","1861.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","292.01","697.91","49","230.56","1861.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","348.96","697.91","91","230.56","1861.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","262.84","525.68","36","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","530.29","657.10","22","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","530.29","530.29","530.29","1 through 10","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2052.54","2052.54","2052.54","1 through 10","230.56","1861.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1323.15","35.54","","1260.85","578.71","10860.00","15","230.56","1861.5","percent of total billed charges",""
"MRI L-Spine W/O Cont|REDUCED SERVICES","PX-61000028","CDM","72148","CPT","0612","RC","","","52","both","","","3723.00","2792.25","MEDICARE [2001]","HB NWH MEDICARE","307.41","","APC Price ($307.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","1168.28","other","OPPS APC"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","both","","","5207.00","3905.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","484.28","484.28","484.28","1 through 10","385.88","3801.11","other","Multiple Radiology"
"MRI Lwr Ext Joint W/Cont","PX-61000063","CDM","73722","CPT","0614","RC","","","","outpatient","","","4299.00","3224.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1527.86","35.54","","1316.11","1316.11","1316.11","1 through 10","691.75","2149.5","percent of total billed charges",""
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","4049.00","3036.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","1157.41","1 through 10","225.91","2955.77","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","4049.00","3036.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.52","628.77","14","225.91","2955.77","other","OPPS APC"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2232.28","2232.28","2232.28","1 through 10","230.56","2024.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","3937.00","3937.00","3937.00","1 through 10","230.56","2024.5","other","Multiple Imaging"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","504.93","262.84","551.04","1 through 10","230.56","2024.5","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1439.01","35.54","","3937.00","530.29","4467.29","16","230.56","2024.5","percent of total billed charges",""
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","4543.00","3407.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","968.56","968.56","1 through 10","385.88","3316.39","other","Multiple Radiology"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","4543.00","3407.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.73","419.73","419.73","1 through 10","385.88","3316.39","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","4543.00","3407.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","415.63","418.63","1 through 10","385.88","3316.39","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4119.00","3089.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","3006.87","other","Multiple Radiology"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4119.00","3089.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.77","284.32","631.77","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4119.00","3089.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2270.84","2270.84","2270.84","1 through 10","230.56","2059.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4119.00","3089.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2059.5","other","Multiple Radiology"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4119.00","3089.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1463.89","35.54","","657.10","530.29","4535.29","14","230.56","2059.5","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","929.97","927.02","968.56","1 through 10","385.88","3149.95","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","34","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","900.30","900.30","900.30","1 through 10","385.88","3149.95","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","992.10","992.10","992.10","1 through 10","385.88","3149.95","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1834.52","415.63","1834.52","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","417.33","417.33","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","488.72","1168.07","1 through 10","385.88","2157.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","488.72","1168.07","22","385.88","2157.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","1 through 10","385.88","2157.5","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","2157.5","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1533.55","35.54","","1461.47","1461.47","1461.47","1 through 10","385.88","2157.5","percent of total billed charges",""
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4119.00","3089.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4119.00","3089.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4119.00","3089.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2059.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4119.00","3089.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","584.01","1 through 10","230.56","2059.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4119.00","3089.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1463.89","35.54","","1394.94","1394.94","1394.94","1 through 10","230.56","2059.5","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","33","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","CHAMPVA [160001]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","385.88","4118.66","other","Tricare OPPS"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","4118.66","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","933.03","968.56","23","385.88","4118.66","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4118.66","73","","4004.78","4004.78","4004.78","1 through 10","385.88","4118.66","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HUMANA [1012]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.97","415.97","415.97","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","274","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","751.87","751.87","751.87","1 through 10","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","884.55","858.94","884.55","16","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","928.78","884.55","928.78","1 through 10","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","974.75","946.53","974.75","43","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","TRICARE [160005]","HB NWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","385.88","4118.66","other","Tricare OPPS"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","417.13","994.86","28","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.34","415.14","421.92","34","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3110.56","3110.56","3110.56","1 through 10","385.88","2821","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","137","385.88","2821","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","1168.07","1168.07","1 through 10","385.88","2821","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","273","385.88","2821","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","82","385.88","2821","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","1099.76","36","385.88","2821","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","2821","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2005.17","35.54","","1910.77","946.92","2499.42","47","385.88","2821","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","631.33","282.47","631.33","1 through 10","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","1938.80","1 through 10","225.91","3066.73","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","13","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","606.24","606.24","606.24","1 through 10","225.91","3066.73","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","668.06","648.71","668.06","1 through 10","225.91","3066.73","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","267.10","284.32","1 through 10","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","697.91","1 through 10","230.56","2100.5","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","21","230.56","2100.5","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","504.93","525.68","1 through 10","230.56","2100.5","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","265.14","578.71","1 through 10","230.56","2100.5","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1493.04","35.54","","1861.13","1422.81","4085.00","1 through 10","230.56","2100.5","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","MEDICARE [2001]","HB NWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","14","385.88","3627.37","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","889.29","889.29","889.29","1 through 10","385.88","3627.37","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","418.43","418.43","1 through 10","385.88","3627.37","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","415.63","424.11","1 through 10","385.88","3627.37","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2739.74","2739.74","2739.74","1 through 10","385.88","2484.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.04","1168.07","1 through 10","385.88","2484.5","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","1168.07","16","385.88","2484.5","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","4832.00","1 through 10","385.88","2484.5","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.98","35.54","","2201.46","940.11","2201.46","1 through 10","385.88","2484.5","percent of total billed charges",""
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","3845.00","2883.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","488.72","488.72","488.72","1 through 10","385.88","1922.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","631.33","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","2735.31","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","34","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","458.46","458.46","458.46","1 through 10","225.91","2735.31","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","505.21","505.21","505.21","1 through 10","225.91","2735.31","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","TRICARE [160005]","HB NWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","225.91","2735.31","other","Tricare OPPS"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","283.32","630.27","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.32","287.06","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2066.15","2066.15","2066.15","1 through 10","230.56","1873.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","348.96","292.01","584.01","13","230.56","1873.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","292.01","697.91","14","230.56","1873.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","1873.5","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","1873.5","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1331.68","35.54","","10932.00","10932.00","10932.00","1 through 10","230.56","1873.5","percent of total billed charges",""
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","3660.00","2745.00","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","641.60","287.06","641.60","1 through 10","225.91","2671.8","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2017.95","2017.95","2017.95","1 through 10","230.56","1830","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","1830","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","348.96","348.96","348.96","1 through 10","230.56","1830","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","1830","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","1830","other","Multiple Radiology"
"MRI Upr Ext Joint W/Cont","PX-61000051","CDM","73222","CPT","0614","RC","","","","both","","","3257.00","2442.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","691.75","","Case rate ($691.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","1736.29","1736.29","1736.29","1 through 10","656.91","2377.61","other","Multiple Radiology"
"MRI Upr Ext Joint W/Cont","PX-61000051","CDM","73222","CPT","0614","RC","","","","outpatient","","","3257.00","2442.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1157.54","35.54","","4440.74","1274.04","4440.74","1 through 10","691.75","2093.94","percent of total billed charges",""
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","3058.00","2293.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","578.71","11","225.91","2232.34","other","Multiple Radiology"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","3058.00","2293.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","284.32","286.32","1 through 10","225.91","2232.34","other","OPPS APC"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","3058.00","2293.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1686.26","1686.26","1686.26","1 through 10","230.56","1529","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","3058.00","2293.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1086.81","35.54","","2974.00","484.55","2974.00","1 through 10","230.56","1529","percent of total billed charges",""
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","both","","","5650.00","4237.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","948.72","948.72","948.72","1 through 10","385.88","4124.5","other","Multiple Radiology"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","outpatient","","","4272.00","3204.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","530.29","530.29","530.29","1 through 10","230.56","2136","other","Multiple Radiology"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","outpatient","","","4272.00","3204.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1518.27","35.54","","4154.00","4154.00","4154.00","1 through 10","230.56","2136","percent of total billed charges",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","126836.56","95127.42","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","64417.66","","Case rate ($62,541.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $64,247.02, add-ons for qualifying new technology services are included. If operating cost exceeds $109,389.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,721.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $57,762.07. The transfer operating threshold is the transfer adjustment factor * $64,247.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,779.35. The transfer capital threshold is the transfer adjustment factor * $4,779.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","63589.33","63589.33","63589.33","1 through 10","61290.59","74098.93","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","126836.56","95127.42","MEDICARE [2001]","HB NWH MEDICARE","68765.85","","Case rate ($68,765.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $64,247.02, add-ons for qualifying new technology services are included. If operating cost exceeds $109,389.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,721.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,986.50. The transfer operating threshold is the transfer adjustment factor * $64,247.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,779.35. The transfer capital threshold is the transfer adjustment factor * $4,779.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","67789.38","59314.94","67911.26","19","61290.59","74098.93","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","126836.56","95127.42","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","61290.59","","Case rate ($62,541.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $64,247.02, add-ons for qualifying new technology services are included. If operating cost exceeds $109,389.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,721.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $57,762.07. The transfer operating threshold is the transfer adjustment factor * $64,247.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,779.35. The transfer capital threshold is the transfer adjustment factor * $4,779.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","60583.26","60583.26","60601.26","1 through 10","61290.59","74098.93","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","126836.56","95127.42","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","61290.59","","Case rate ($62,541.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $64,247.02, add-ons for qualifying new technology services are included. If operating cost exceeds $109,389.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,721.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $57,762.07. The transfer operating threshold is the transfer adjustment factor * $64,247.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,779.35. The transfer capital threshold is the transfer adjustment factor * $4,779.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","68228.04","68228.04","68228.04","1 through 10","61290.59","74098.93","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","165319.10","123989.32","MEDICARE [2001]","HB NWH MEDICARE","104990.18","","Case rate ($104,990.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $98,090.93, add-ons for qualifying new technology services are included. If operating cost exceeds $143,233.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $10,238.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $97,693.18. The transfer operating threshold is the transfer adjustment factor * $98,090.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,297.01. The transfer capital threshold is the transfer adjustment factor * $7,297.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","83021.59","83021.59","96202.48","1 through 10","93577.12","104990.18","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","165319.10","123989.32","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","93577.12","","Case rate ($95,486.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $98,090.93, add-ons for qualifying new technology services are included. If operating cost exceeds $143,233.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $10,238.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $88,189.85. The transfer operating threshold is the transfer adjustment factor * $98,090.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,297.01. The transfer capital threshold is the transfer adjustment factor * $7,297.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","89322.62","89322.62","89322.62","1 through 10","93577.12","104990.18","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","165319.10","123989.32","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","93577.12","","Case rate ($95,486.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $98,090.93, add-ons for qualifying new technology services are included. If operating cost exceeds $143,233.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $10,238.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $88,189.85. The transfer operating threshold is the transfer adjustment factor * $98,090.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,297.01. The transfer capital threshold is the transfer adjustment factor * $7,297.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","89363.62","89331.04","89367.61","1 through 10","93577.12","104990.18","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","101686.58","76264.93","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","48708.59","","Case rate ($48,708.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $50,036.95, add-ons for qualifying new technology services are included. If operating cost exceeds $95,179.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,664.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,986.33. The transfer operating threshold is the transfer adjustment factor * $50,036.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,722.26. The transfer capital threshold is the transfer adjustment factor * $3,722.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","47463.73","47463.73","47464.40","1 through 10","47734.42","57709.83","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","101686.58","76264.93","MEDICARE [2001]","HB NWH MEDICARE","48708.59","","Case rate ($48,708.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $50,036.95, add-ons for qualifying new technology services are included. If operating cost exceeds $95,179.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,664.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,986.33. The transfer operating threshold is the transfer adjustment factor * $50,036.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,722.26. The transfer capital threshold is the transfer adjustment factor * $3,722.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52532.06","52532.06","52626.50","13","47734.42","57709.83","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","101686.58","76264.93","MOLINA [1014]","HB NWH MEDICARE","48708.59","","Case rate ($48,708.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $50,036.95, add-ons for qualifying new technology services are included. If operating cost exceeds $95,179.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,664.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,986.33. The transfer operating threshold is the transfer adjustment factor * $50,036.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,722.26. The transfer capital threshold is the transfer adjustment factor * $3,722.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59558.06","59558.06","59558.06","1 through 10","47734.42","57709.83","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","116243.25","87182.44","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","59625.56","","Case rate ($57,888.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $59,467.61, add-ons for qualifying new technology services are included. If operating cost exceeds $104,609.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,365.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $53,465.08. The transfer operating threshold is the transfer adjustment factor * $59,467.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,423.81. The transfer capital threshold is the transfer adjustment factor * $4,423.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","60027.71","60027.71","60027.71","1 through 10","56731.11","66302.7783","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","116243.25","87182.44","MEDICARE [2001]","HB NWH MEDICARE","63650.28","","Case rate ($63,650.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $59,467.61, add-ons for qualifying new technology services are included. If operating cost exceeds $104,609.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,365.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $59,226.47. The transfer operating threshold is the transfer adjustment factor * $59,467.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,423.81. The transfer capital threshold is the transfer adjustment factor * $4,423.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63989.97","63989.97","63989.97","1 through 10","56731.11","66302.7783","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","89021.62","66766.21","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","37844.25","","Case rate ($36,741.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,743.99, add-ons for qualifying new technology services are included. If operating cost exceeds $82,886.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,749.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $33,934.19. The transfer operating threshold is the transfer adjustment factor * $37,743.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,807.78. The transfer capital threshold is the transfer adjustment factor * $2,807.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","36566.80","36566.80","36566.80","1 through 10","36007.15","43531.81","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","89021.62","66766.21","MEDICARE [2001]","HB NWH MEDICARE","40398.73","","Case rate ($40,398.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,743.99, add-ons for qualifying new technology services are included. If operating cost exceeds $82,886.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,749.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,590.94. The transfer operating threshold is the transfer adjustment factor * $37,743.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,807.78. The transfer capital threshold is the transfer adjustment factor * $2,807.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38973.11","37757.64","39043.68","19","36007.15","43531.81","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","89021.62","66766.21","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","36007.15","","Case rate ($36,741.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,743.99, add-ons for qualifying new technology services are included. If operating cost exceeds $82,886.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,749.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $33,934.19. The transfer operating threshold is the transfer adjustment factor * $37,743.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,807.78. The transfer capital threshold is the transfer adjustment factor * $2,807.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","34834.95","34834.95","34834.95","1 through 10","36007.15","43531.81","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","","","","inpatient","","","28645.00","21483.75","MEDICARE [2001]","HB NWH MEDICARE","11821.06","","Case rate ($11,821.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,044.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,186.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,763.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,999.48. The transfer operating threshold is the transfer adjustment factor * $11,044.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $821.59. The transfer capital threshold is the transfer adjustment factor * $821.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11699.25","11699.25","11699.25","1 through 10","10536.04","12100.1804","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","","","","inpatient","","","28645.00","21483.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","10536.04","","Case rate ($10,751.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,044.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,186.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,763.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,929.48. The transfer operating threshold is the transfer adjustment factor * $11,044.26 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $821.59. The transfer capital threshold is the transfer adjustment factor * $821.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17.22","17.22","17.22","1 through 10","10536.04","12100.1804","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With McC","058","MS-DRG","","","","","","","","inpatient","","","37414.14","28060.60","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14810.98","","Case rate ($14,810.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,214.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,357.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,073.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,679.14. The transfer operating threshold is the transfer adjustment factor * $15,214.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,131.84. The transfer capital threshold is the transfer adjustment factor * $1,131.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15917.83","15917.83","15917.83","1 through 10","14514.76","17548.02","other","Inpatient Replacement Plans DRG"
"Multiple Sclerosis And Cerebellar Ataxia With McC","058","MS-DRG","","","","","","","","inpatient","","","37414.14","28060.60","MEDICARE [2001]","HB NWH MEDICARE","14810.98","","Case rate ($14,810.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,214.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,357.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,073.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,679.14. The transfer operating threshold is the transfer adjustment factor * $15,214.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,131.84. The transfer capital threshold is the transfer adjustment factor * $1,131.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17649.26","17649.26","17649.26","1 through 10","14514.76","17548.02","other","Inpatient Replacement Plans DRG"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC","060","MS-DRG","","","","","","","","inpatient","","","29707.81","22280.86","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8208.15","","Case rate ($7,969.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,186.41, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.09. The transfer operating threshold is the transfer adjustment factor * $8,186.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.99. The transfer capital threshold is the transfer adjustment factor * $608.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8026.69","8026.69","8026.69","1 through 10","7809.7","8824.9436","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC","060","MS-DRG","","","","","","","","inpatient","","","29707.81","22280.86","MEDICARE [2001]","HB NWH MEDICARE","7969.08","","Case rate ($7,969.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,186.41, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,550.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,360.09. The transfer operating threshold is the transfer adjustment factor * $8,186.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.99. The transfer capital threshold is the transfer adjustment factor * $608.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8532.52","8532.52","8532.52","1 through 10","7809.7","8824.9436","other","Inpatient Replacement Plans DRG"
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MINOR","043","DRG","","","","","","","","inpatient","","","31915.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20698.52","","Standard inlier is a Case rate ($20,698.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,938.07) for the length of stay and the standard reimbursement.","19757.68","19757.68","19757.68","1 through 10","6897.51","56385.08","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MINOR","043","DRG","","","","","","","","inpatient","","","31915.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14105.4156","","Fee schedule rate ($14,105.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.4156","14105.42","14105.42","1 through 10","6897.51","56385.08","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MODERATE","043","DRG","","","","","","","","inpatient","","","23626.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20698.52","","Standard inlier is a Case rate ($20,698.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,938.07) for the length of stay and the standard reimbursement.","3077.82","3077.82","3077.82","1 through 10","6897.51","56385.08","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MODERATE","043","DRG","","","","","","","","inpatient","","","23626.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14105.4156","","Fee schedule rate ($15,747.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.4156","18525.82","18525.82","1 through 10","6897.51","56385.08","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MODERATE","930","DRG","","","","","","","","inpatient","","","29306.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23711.13","","Standard inlier is a Case rate ($23,711.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,293, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,365.70) for the length of stay and the standard reimbursement.","22633.35","22633.35","22633.35","1 through 10","8988.14","32476.16","case rate",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.48","84.48","84.48","13","12.79","145.35","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","114.55","67.88","114.55","1 through 10","12.79","145.35","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.31","14","13.45","120.03","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","114.55","67.88","114.55","13","13.45","120.03","percent of total billed charges",""
"Muramidase","PX-30001111","CDM","85549","CPT","0305","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.81","78.45","","68.34","68.34","68.34","1 through 10","19.35","120.81","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","90.59","57.7","","176.41","176.41","176.41","1 through 10","46.11","123.17","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","117.63","69.71","117.63","1 through 10","46.11","123.17","percent of total billed charges",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MAJOR","912","DRG","","","","","","","","inpatient","","","65553.87","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","28998.96","","Case rate ($31,241.80). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $73,671.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,068.94 and the sum of the standard inlier and any outlier amount.","31322.15","31322.15","31322.15","1 through 10","28998.96","138887.81","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","30655.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21531.52","","Fee schedule rate ($21,531.52). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,490.86) multiplied by length of stay and the outlier percent (100%).","38078.51","38078.51","38078.51","1 through 10","2181","62446.95","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","30655.24","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15741.081","","Per diem ($4,205). If length of stay < 9, first 1 days paid at a per diem of $8,410 instead.","15741.081","8409.60","8409.60","1 through 10","2181","62446.95","per diem","Estimated amount calculated based on 1 day length of stay."
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.74","59.3","","78.90","78.90","78.90","1 through 10","10.76","73.74","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","69.96","69.96","1 through 10","10.76","73.74","percent of total billed charges",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","41488.16","31116.12","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","19623.59","","Case rate ($20,024.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,570.15, add-ons for qualifying new technology services are included. If operating cost exceeds $65,712.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,472.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $18,493.85. The transfer operating threshold is the transfer adjustment factor * $20,570.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,530.22. The transfer capital threshold is the transfer adjustment factor * $1,530.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20123.52","20123.52","20123.52","1 through 10","19623.59","23337.0511","other","Inpatient DRG"
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","413.34","413.34","413.34","1 through 10","333.38","584.33","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","574.16","574.16","574.16","1 through 10","333.38","584.33","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","427.19","416.99","427.19","1 through 10","375","588.38","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","560.46","332.13","560.46","1 through 10","375","588.38","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.78","82.78","82.78","1 through 10","12.66","142.5","percent of total billed charges",""
"Myomectomy <250grams Vag","PX-76001380","CDM","58145","CPT","0761","RC","","","","outpatient","","","8940.00","6705.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5301.42","59.3","","2422.52","2422.52","2422.52","1 through 10","3576","7013.43","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","AETNA [1001]","HB CH AETNA HMO / PPO","3941.66","58.3","","3727.46","3727.46","10916.45","1 through 10","1147.8","6429.71","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1244.33","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1244.05","1243.25","6574.00","1 through 10","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1188.88","1188.88","11","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","4286.47","63.4","","12764.74","4358.56","12764.74","1 through 10","1147.8","6429.71","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","HUMANA [1012]","HB NWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1188.88","1188.88","1 through 10","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","INTERNATIONAL COMMERCIAL [140001]","HB CH GMMI INTERNATIONAL","3583.33","53","","10204.09","10204.09","10204.09","1 through 10","1147.8","6429.71","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","MARTIN'S POINT [160007]","HB NWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","MEDICARE [2001]","HB NWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","101","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","MOLINA [1014]","HB NWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.09","2397.09","2397.09","1 through 10","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1183.93","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1186.05","1184.05","3556.15","20","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1183.93","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.55","1118.30","1185.05","16","1147.8","6429.71","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","6761.00","5070.75","WELLPOINT [1015]","HB CH WELLPOINT","5267.50","77.91","","5177.68","5177.68","5177.68","1 through 10","1147.8","6429.71","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","4009.27","59.3","","3852.36","3852.36","11282.26","1 through 10","1578.64","5304","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3901.10","57.7","","3964.12","3964.12","11609.56","13","1578.64","5304","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","4090.41","60.5","","4161.34","4161.34","4161.34","1 through 10","1578.64","5304","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5304.00","78.45","","14801.71","14801.71","14801.71","1 through 10","1578.64","5304","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","4090.41","60.5","","5054.09","5054.09","5054.09","1 through 10","1578.64","5304","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","6761.00","5070.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5304.00","78.45","","5054.09","2995.11","6705.82","1 through 10","1578.64","5304","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","AETNA [1001]","HB CH AETNA HMO / PPO","3537.32","58.3","","464.71","67.87","1012.10","221","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3537.32","58.3","","293.04","293.04","293.04","11","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3215.74","53","","983.89","983.89","983.89","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3519.12","58","","677.18","677.18","677.18","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3792.15","62.5","","46.58","46.58","46.58","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","747.15","747.15","747.15","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","1141.67","481.21","1141.67","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","76.54","76.54","76.54","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","WELLPOINT [1015]","HB CH WELLPOINT","4727.14","77.91","","273.64","94.28","1367.51","138","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","3597.99","59.3","","720.78","230.14","2010.94","427","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3597.99","59.3","","344.45","344.45","344.45","1 through 10","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","1120.13","1120.13","1120.13","1 through 10","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 11X150MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","456.17","105.33","1284.66","242","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","AETNA [1001]","HB CH AETNA HMO / PPO","3537.32","58.3","","464.71","67.87","1012.10","221","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3537.32","58.3","","293.04","293.04","293.04","11","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3215.74","53","","983.89","983.89","983.89","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3519.12","58","","677.18","677.18","677.18","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3792.15","62.5","","46.58","46.58","46.58","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","747.15","747.15","747.15","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","1141.67","481.21","1141.67","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","76.54","76.54","76.54","1 through 10","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","WELLPOINT [1015]","HB CH WELLPOINT","4727.14","77.91","","273.64","94.28","1367.51","138","2696.98","4727.14","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","3597.99","59.3","","720.78","230.14","2010.94","427","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3597.99","59.3","","344.45","344.45","344.45","1 through 10","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","1120.13","1120.13","1120.13","1 through 10","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X150MM T2 LEFT","SUP-ITM-10033508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","456.17","105.33","1284.66","242","3033.72","4759.91","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","AETNA [1001]","HB CH AETNA HMO / PPO","324.23","58.3","","464.71","67.87","1012.10","221","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","324.23","58.3","","293.04","293.04","293.04","11","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.75","53","","983.89","983.89","983.89","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","322.56","58","","677.18","677.18","677.18","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","347.59","62.5","","46.58","46.58","46.58","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.98","73","","747.15","747.15","747.15","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.20","44.45","","1141.67","481.21","1141.67","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.20","44.45","","76.54","76.54","76.54","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","WELLPOINT [1015]","HB CH WELLPOINT","433.29","77.91","","273.64","94.28","1367.51","138","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.79","59.3","","720.78","230.14","2010.94","427","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","329.79","59.3","","344.45","344.45","344.45","1 through 10","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","436.29","78.45","","1120.13","1120.13","1120.13","1 through 10","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X16MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","436.29","78.45","","456.17","105.33","1284.66","242","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","AETNA [1001]","HB CH AETNA HMO / PPO","324.23","58.3","","464.71","67.87","1012.10","221","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","324.23","58.3","","293.04","293.04","293.04","11","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.75","53","","983.89","983.89","983.89","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","322.56","58","","677.18","677.18","677.18","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","347.59","62.5","","46.58","46.58","46.58","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.98","73","","747.15","747.15","747.15","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.20","44.45","","1141.67","481.21","1141.67","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.20","44.45","","76.54","76.54","76.54","1 through 10","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","556.14","417.10","WELLPOINT [1015]","HB CH WELLPOINT","433.29","77.91","","273.64","94.28","1367.51","138","247.2","433.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.79","59.3","","720.78","230.14","2010.94","427","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","329.79","59.3","","344.45","344.45","344.45","1 through 10","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","436.29","78.45","","1120.13","1120.13","1120.13","1 through 10","278.07","436.29","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","556.14","417.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","436.29","78.45","","456.17","105.33","1284.66","242","278.07","436.29","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","AETNA [1001]","HB CH AETNA HMO / PPO","3946.91","58.3","","464.71","67.87","1012.10","221","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3946.91","58.3","","293.04","293.04","293.04","11","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3588.10","53","","983.89","983.89","983.89","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3926.60","58","","677.18","677.18","677.18","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4231.25","62.5","","46.58","46.58","46.58","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4942.10","73","","747.15","747.15","747.15","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3009.27","44.45","","1141.67","481.21","1141.67","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3009.27","44.45","","76.54","76.54","76.54","1 through 10","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6770.00","5077.50","WELLPOINT [1015]","HB CH WELLPOINT","5274.51","77.91","","273.64","94.28","1367.51","138","3009.27","5274.51","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6770.00","5077.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4014.61","59.3","","720.78","230.14","2010.94","427","3385","5311.07","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6770.00","5077.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4014.61","59.3","","344.45","344.45","344.45","1 through 10","3385","5311.07","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6770.00","5077.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5311.07","78.45","","1120.13","1120.13","1120.13","1 through 10","3385","5311.07","percent of total billed charges",""
"NAIL BONE 10MMX20CM 125DEG FEMORAL TRIGEN INTERTAN 10S","SUP-ITM-10282799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6770.00","5077.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5311.07","78.45","","456.17","105.33","1284.66","242","3385","5311.07","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 10X300MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","AETNA [1001]","HB CH AETNA HMO / PPO","5270.32","58.3","","464.71","67.87","1012.10","221","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5270.32","58.3","","293.04","293.04","293.04","11","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4791.20","53","","983.89","983.89","983.89","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5243.20","58","","677.18","677.18","677.18","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5650.00","62.5","","46.58","46.58","46.58","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6599.20","73","","747.15","747.15","747.15","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4018.28","44.45","","1141.67","481.21","1141.67","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4018.28","44.45","","76.54","76.54","76.54","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","WELLPOINT [1015]","HB CH WELLPOINT","7043.06","77.91","","273.64","94.28","1367.51","138","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5360.72","59.3","","720.78","230.14","2010.94","427","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5360.72","59.3","","344.45","344.45","344.45","1 through 10","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7091.88","78.45","","1120.13","1120.13","1120.13","1 through 10","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX38CM 125DEG FEMORAL TRIGEN INTERTAN TITANIUM INTERTROCHANTERIC ANTEGRADE LT LIME 71676557","SUP-ITM-10099062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7091.88","78.45","","456.17","105.33","1284.66","242","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","AETNA [1001]","HB CH AETNA HMO / PPO","5270.32","58.3","","464.71","67.87","1012.10","221","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5270.32","58.3","","293.04","293.04","293.04","11","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4791.20","53","","983.89","983.89","983.89","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5243.20","58","","677.18","677.18","677.18","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5650.00","62.5","","46.58","46.58","46.58","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6599.20","73","","747.15","747.15","747.15","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4018.28","44.45","","1141.67","481.21","1141.67","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4018.28","44.45","","76.54","76.54","76.54","1 through 10","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","both","","","9040.00","6780.00","WELLPOINT [1015]","HB CH WELLPOINT","7043.06","77.91","","273.64","94.28","1367.51","138","4018.28","7043.06","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5360.72","59.3","","720.78","230.14","2010.94","427","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5360.72","59.3","","344.45","344.45","344.45","1 through 10","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7091.88","78.45","","1120.13","1120.13","1120.13","1 through 10","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11.5MMX40CM 125DEG TRIGEN INTERTAN 1.5 TITANIUM INTRAMEDULLARY FEMORAL LEFT","SUP-ITM-10099060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9040.00","6780.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7091.88","78.45","","456.17","105.33","1284.66","242","4520","7091.88","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","AETNA [1001]","HB CH AETNA HMO / PPO","2736.32","58.3","","2190.90","412.50","9264.59","16","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2722.24","58","","1903.20","1903.20","3826.66","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2933.45","62.5","","2186.25","2186.25","2186.25","32","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3426.27","73","","5556.60","5556.60","5556.60","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","WELLPOINT [1015]","HB CH WELLPOINT","3656.72","77.91","","1955.15","885.83","3150.40","26","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","2783.26","59.3","","831.03","253.22","2394.88","18","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 11X300MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10028274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3682.07","78.45","","2481.69","1563.74","8149.28","1 through 10","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","464.71","67.87","1012.10","221","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","293.04","293.04","293.04","11","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","983.89","983.89","983.89","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2351.48","58","","677.18","677.18","677.18","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2533.93","62.5","","46.58","46.58","46.58","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","747.15","747.15","747.15","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","1141.67","481.21","1141.67","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","76.54","76.54","76.54","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","273.64","94.28","1367.51","138","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","720.78","230.14","2010.94","427","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2404.19","59.3","","344.45","344.45","344.45","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","1120.13","1120.13","1120.13","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","456.17","105.33","1284.66","242","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","AETNA [1001]","HB CH AETNA HMO / PPO","3592.67","58.3","","464.71","67.87","1012.10","221","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3592.67","58.3","","293.04","293.04","293.04","11","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3266.06","53","","983.89","983.89","983.89","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3574.18","58","","677.18","677.18","677.18","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3851.49","62.5","","46.58","46.58","46.58","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4498.54","73","","747.15","747.15","747.15","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2739.18","44.45","","1141.67","481.21","1141.67","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2739.18","44.45","","76.54","76.54","76.54","1 through 10","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","both","","","6162.38","4621.78","WELLPOINT [1015]","HB CH WELLPOINT","4801.11","77.91","","273.64","94.28","1367.51","138","2739.18","4801.11","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6162.38","4621.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","3654.29","59.3","","720.78","230.14","2010.94","427","3081.19","4834.39","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6162.38","4621.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3654.29","59.3","","344.45","344.45","344.45","1 through 10","3081.19","4834.39","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6162.38","4621.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4834.39","78.45","","1120.13","1120.13","1120.13","1 through 10","3081.19","4834.39","percent of total billed charges",""
"NAIL BONE 12X320MM FEMORAL T2 TITANIUM SUPRACONDYLAR","SUP-ITM-10033664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6162.38","4621.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4834.39","78.45","","456.17","105.33","1284.66","242","3081.19","4834.39","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","464.71","67.87","1012.10","221","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","293.04","293.04","293.04","11","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","983.89","983.89","983.89","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2351.48","58","","677.18","677.18","677.18","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2533.93","62.5","","46.58","46.58","46.58","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","747.15","747.15","747.15","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","1141.67","481.21","1141.67","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","76.54","76.54","76.54","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","273.64","94.28","1367.51","138","1802.13","3158.69","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","720.78","230.14","2010.94","427","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2404.19","59.3","","344.45","344.45","344.45","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","1120.13","1120.13","1120.13","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","456.17","105.33","1284.66","242","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","AETNA [1001]","HB CH AETNA HMO / PPO","2178.24","58.3","","464.71","67.87","1012.10","221","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.24","58.3","","293.04","293.04","293.04","11","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.22","53","","983.89","983.89","983.89","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.03","58","","677.18","677.18","677.18","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.16","62.5","","46.58","46.58","46.58","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","747.15","747.15","747.15","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","1141.67","481.21","1141.67","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","76.54","76.54","76.54","1 through 10","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","WELLPOINT [1015]","HB CH WELLPOINT","2910.92","77.91","","273.64","94.28","1367.51","138","1660.77","2910.92","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2215.60","59.3","","720.78","230.14","2010.94","427","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2215.60","59.3","","344.45","344.45","344.45","1 through 10","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","456.17","105.33","1284.66","242","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","AETNA [1001]","HB CH AETNA HMO / PPO","2736.32","58.3","","464.71","67.87","1012.10","221","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2736.32","58.3","","293.04","293.04","293.04","11","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2487.57","53","","983.89","983.89","983.89","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2722.24","58","","677.18","677.18","677.18","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2933.45","62.5","","46.58","46.58","46.58","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3426.27","73","","747.15","747.15","747.15","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2086.27","44.45","","1141.67","481.21","1141.67","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2086.27","44.45","","76.54","76.54","76.54","1 through 10","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4693.52","3520.14","WELLPOINT [1015]","HB CH WELLPOINT","3656.72","77.91","","273.64","94.28","1367.51","138","2086.27","3656.72","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","2783.26","59.3","","720.78","230.14","2010.94","427","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2783.26","59.3","","344.45","344.45","344.45","1 through 10","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3682.07","78.45","","1120.13","1120.13","1120.13","1 through 10","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 360X11MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4693.52","3520.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3682.07","78.45","","456.17","105.33","1284.66","242","2346.76","3682.07","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","AETNA [1001]","HB CH AETNA HMO / PPO","1906.41","58.3","","464.71","67.87","1012.10","221","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1906.41","58.3","","293.04","293.04","293.04","11","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1733.10","53","","983.89","983.89","983.89","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1896.60","58","","677.18","677.18","677.18","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2043.75","62.5","","46.58","46.58","46.58","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2387.10","73","","747.15","747.15","747.15","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.52","44.45","","1141.67","481.21","1141.67","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.52","44.45","","76.54","76.54","76.54","1 through 10","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","WELLPOINT [1015]","HB CH WELLPOINT","2547.66","77.91","","273.64","94.28","1367.51","138","1453.52","2547.66","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1939.11","59.3","","720.78","230.14","2010.94","427","1635","2565.32","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1939.11","59.3","","344.45","344.45","344.45","1 through 10","1635","2565.32","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2565.32","78.45","","1120.13","1120.13","1120.13","1 through 10","1635","2565.32","percent of total billed charges",""
"NAIL BONE 4MMX38CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2565.32","78.45","","456.17","105.33","1284.66","242","1635","2565.32","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","AETNA [1001]","HB CH AETNA HMO / PPO","2166.27","58.3","","464.71","67.87","1012.10","221","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2166.27","58.3","","293.04","293.04","293.04","11","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1969.34","53","","983.89","983.89","983.89","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2155.12","58","","677.18","677.18","677.18","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2322.33","62.5","","46.58","46.58","46.58","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2712.48","73","","747.15","747.15","747.15","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.64","44.45","","1141.67","481.21","1141.67","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.64","44.45","","76.54","76.54","76.54","1 through 10","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","WELLPOINT [1015]","HB CH WELLPOINT","2894.93","77.91","","273.64","94.28","1367.51","138","1651.64","2894.93","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","2203.43","59.3","","720.78","230.14","2010.94","427","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2203.43","59.3","","344.45","344.45","344.45","1 through 10","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2914.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 7X240MM HUMERAL TITANIUM CANNULATED MULTILOC LEFT","SUP-ITM-10125441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2914.99","78.45","","456.17","105.33","1284.66","242","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL BONE 9X315MM TIBIAL EX TITANIUM CANNULATED","SUP-ITM-10018760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","AETNA [1001]","HB CH AETNA HMO / PPO","2606.55","58.3","","464.71","67.87","1012.10","221","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2606.55","58.3","","293.04","293.04","293.04","11","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2369.59","53","","983.89","983.89","983.89","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2593.14","58","","677.18","677.18","677.18","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2794.33","62.5","","46.58","46.58","46.58","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3263.78","73","","747.15","747.15","747.15","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1987.33","44.45","","1141.67","481.21","1141.67","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1987.33","44.45","","76.54","76.54","76.54","1 through 10","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","both","","","4470.93","3353.20","WELLPOINT [1015]","HB CH WELLPOINT","3483.30","77.91","","273.64","94.28","1367.51","138","1987.33","3483.3","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4470.93","3353.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","2651.26","59.3","","720.78","230.14","2010.94","427","2235.47","3507.44","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4470.93","3353.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2651.26","59.3","","344.45","344.45","344.45","1 through 10","2235.47","3507.44","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4470.93","3353.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3507.44","78.45","","1120.13","1120.13","1120.13","1 through 10","2235.47","3507.44","percent of total billed charges",""
"NAIL FEMORAL 10X200MM 10DEG BEND RETROGRADE","SUP-ITM-10296078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4470.93","3353.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3507.44","78.45","","456.17","105.33","1284.66","242","2235.47","3507.44","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","AETNA [1001]","HB CH AETNA HMO / PPO","2006.45","58.3","","464.71","67.87","1012.10","221","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2006.45","58.3","","293.04","293.04","293.04","11","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1824.05","53","","983.89","983.89","983.89","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1996.13","58","","677.18","677.18","677.18","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2151.00","62.5","","46.58","46.58","46.58","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2512.37","73","","747.15","747.15","747.15","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.79","44.45","","1141.67","481.21","1141.67","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.79","44.45","","76.54","76.54","76.54","1 through 10","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","3441.60","2581.20","WELLPOINT [1015]","HB CH WELLPOINT","2681.35","77.91","","273.64","94.28","1367.51","138","1529.79","2681.35","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3441.60","2581.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.87","59.3","","720.78","230.14","2010.94","427","1720.8","2699.94","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3441.60","2581.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2040.87","59.3","","344.45","344.45","344.45","1 through 10","1720.8","2699.94","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3441.60","2581.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2699.94","78.45","","1120.13","1120.13","1120.13","1 through 10","1720.8","2699.94","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3441.60","2581.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.94","78.45","","456.17","105.33","1284.66","242","1720.8","2699.94","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","464.71","67.87","1012.10","221","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","293.04","293.04","293.04","11","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","983.89","983.89","983.89","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2351.48","58","","677.18","677.18","677.18","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2533.93","62.5","","46.58","46.58","46.58","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","747.15","747.15","747.15","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","1141.67","481.21","1141.67","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","76.54","76.54","76.54","1 through 10","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","273.64","94.28","1367.51","138","1802.13","3158.69","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","720.78","230.14","2010.94","427","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2404.19","59.3","","344.45","344.45","344.45","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","1120.13","1120.13","1120.13","1 through 10","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","456.17","105.33","1284.66","242","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","AETNA [1001]","HB CH AETNA HMO / PPO","4195.61","58.3","","464.71","67.87","1012.10","221","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4195.61","58.3","","293.04","293.04","293.04","11","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3814.19","53","","983.89","983.89","983.89","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4174.02","58","","677.18","677.18","677.18","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4497.86","62.5","","46.58","46.58","46.58","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","747.15","747.15","747.15","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","1141.67","481.21","1141.67","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","76.54","76.54","76.54","1 through 10","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","WELLPOINT [1015]","HB CH WELLPOINT","5606.86","77.91","","273.64","94.28","1367.51","138","3198.88","5606.86","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4267.57","59.3","","720.78","230.14","2010.94","427","3598.29","5645.72","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4267.57","59.3","","344.45","344.45","344.45","1 through 10","3598.29","5645.72","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","1120.13","1120.13","1120.13","1 through 10","3598.29","5645.72","percent of total billed charges",""
"NAIL FEMUR 13X360MM TITANIUM LT LONG 125 DEG","SUP-ITM-10142163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","456.17","105.33","1284.66","242","3598.29","5645.72","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","AETNA [1001]","HB CH AETNA HMO / PPO","902.48","58.3","","464.71","67.87","1012.10","221","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","902.48","58.3","","293.04","293.04","293.04","11","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","820.44","53","","983.89","983.89","983.89","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","897.84","58","","677.18","677.18","677.18","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","967.50","62.5","","46.58","46.58","46.58","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1130.04","73","","747.15","747.15","747.15","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","688.09","44.45","","1141.67","481.21","1141.67","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","688.09","44.45","","76.54","76.54","76.54","1 through 10","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1548.00","1161.00","WELLPOINT [1015]","HB CH WELLPOINT","1206.05","77.91","","273.64","94.28","1367.51","138","688.09","1206.05","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1548.00","1161.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","917.96","59.3","","720.78","230.14","2010.94","427","774","1214.41","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1548.00","1161.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","917.96","59.3","","344.45","344.45","344.45","1 through 10","774","1214.41","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1548.00","1161.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1214.41","78.45","","1120.13","1120.13","1120.13","1 through 10","774","1214.41","percent of total billed charges",""
"NAIL INTRAMEDULLARY 1.5X300MMPEDIFLEX ADVANCED TITANIUM ROUND TIP","SUP-ITM-10270086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1548.00","1161.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1214.41","78.45","","456.17","105.33","1284.66","242","774","1214.41","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","AETNA [1001]","HB CH AETNA HMO / PPO","3754.94","58.3","","464.71","67.87","1012.10","221","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3754.94","58.3","","293.04","293.04","293.04","11","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3413.58","53","","983.89","983.89","983.89","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3735.62","58","","677.18","677.18","677.18","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4025.45","62.5","","46.58","46.58","46.58","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4701.73","73","","747.15","747.15","747.15","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2862.90","44.45","","1141.67","481.21","1141.67","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2862.90","44.45","","76.54","76.54","76.54","1 through 10","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","both","","","6440.72","4830.54","WELLPOINT [1015]","HB CH WELLPOINT","5017.96","77.91","","273.64","94.28","1367.51","138","2862.9","5017.96","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6440.72","4830.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","3819.35","59.3","","720.78","230.14","2010.94","427","3220.36","5052.74","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6440.72","4830.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3819.35","59.3","","344.45","344.45","344.45","1 through 10","3220.36","5052.74","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6440.72","4830.54","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5052.74","78.45","","1120.13","1120.13","1120.13","1 through 10","3220.36","5052.74","percent of total billed charges",""
"NAIL RECONSTRUCTION 9X380MM 125 RIGHT","SUP-ITM-10141364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6440.72","4830.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5052.74","78.45","","456.17","105.33","1284.66","242","3220.36","5052.74","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 10X345MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","464.71","67.87","1012.10","221","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","293.04","293.04","293.04","11","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","983.89","983.89","983.89","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.06","58","","677.18","677.18","677.18","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2091.66","62.5","","46.58","46.58","46.58","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","747.15","747.15","747.15","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","1141.67","481.21","1141.67","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","76.54","76.54","76.54","1 through 10","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","273.64","94.28","1367.51","138","1487.59","2607.38","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","720.78","230.14","2010.94","427","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1984.56","59.3","","344.45","344.45","344.45","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","456.17","105.33","1284.66","242","1673.33","2625.45","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0300","RC","","","","inpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","273.22","70.6","","578.14","289.07","578.14","1 through 10","216.72","273.22","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB CH AETNA HMO / PPO","225.62","58.3","","213.19","213.19","213.19","33","38.47","367.65","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","387.00","290.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.49","59.3","","220.34","220.34","1175.89","43","35.01","303.6","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","289.07","171.31","289.07","23","35.01","303.6","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","74.28","1 through 10","36.98","222.6","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","100.71","100.71","100.71","1 through 10","36.98","222.6","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","101.82","101.82","101.82","1 through 10","11.81","141.69","percent of total billed charges",""
"Needle Aspirate/Biopsy Peritonsillar Collection","PX-76002634","CDM","42999","CPT","0761","RC","","","","outpatient","","","926.00","694.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","463.93","50.1","","900.00","900.00","900.00","1 through 10","397.25","726.45","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1050.60","787.95","AETNA [1001]","HB CH AETNA HMO / PPO","612.50","58.3","","34.02","34.02","34.02","1 through 10","556.82","999.12","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1050.60","787.95","WELLPOINT [1015]","HB CH WELLPOINT","818.52","77.91","","47.26","47.26","47.26","1 through 10","556.82","999.12","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1050.60","787.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","623.01","59.3","","105.48","70.32","105.48","1 through 10","466.99","824.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1050.60","787.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.99","44.45","","26.94","26.94","26.94","1 through 10","466.99","824.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1050.60","787.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","824.20","78.45","","46.13","27.34","92.26","1 through 10","466.99","824.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1050.60","787.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.99","44.45","","46.13","46.13","46.13","1 through 10","466.99","824.2","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","AETNA [1001]","HB CH AETNA HMO / PPO","409.27","58.3","","464.71","67.87","1012.10","221","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.27","58.3","","293.04","293.04","293.04","11","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.06","53","","983.89","983.89","983.89","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","407.16","58","","677.18","677.18","677.18","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","438.75","62.5","","46.58","46.58","46.58","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.46","73","","747.15","747.15","747.15","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.04","44.45","","1141.67","481.21","1141.67","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.04","44.45","","76.54","76.54","76.54","1 through 10","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","WELLPOINT [1015]","HB CH WELLPOINT","546.93","77.91","","273.64","94.28","1367.51","138","312.04","546.93","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.29","59.3","","720.78","230.14","2010.94","427","351","550.72","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","416.29","59.3","","344.45","344.45","344.45","1 through 10","351","550.72","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","550.72","78.45","","1120.13","1120.13","1120.13","1 through 10","351","550.72","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","550.72","78.45","","456.17","105.33","1284.66","242","351","550.72","percent of total billed charges",""
"Neonatal Aftercare,EXTREME","863","DRG","","","","","","","","inpatient","","","171946.70","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","109661.42","","Case rate ($118,142.87). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $160,572.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","148058.37","148058.37","148058.37","1 through 10","1361","246674.36","case rate",""
"Neonatal Aftercare,MAJOR","863","DRG","","","","","","","","inpatient","","","107453.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","102401.61","","Standard inlier is a Case rate ($102,401.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $116,700, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,536.31) for the length of stay and the standard reimbursement.","102401.60","102401.60","102401.60","1 through 10","1361","246674.36","case rate",""
"Neonatal Aftercare,MAJOR","863","DRG","","","","","","","","inpatient","","","107453.45","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","40304.96","","Case rate ($43,422.23). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $85,852.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","67083.10","67083.10","67083.10","1 through 10","1361","246674.36","case rate",""
"Neonatal Aftercare,MODERATE","863","DRG","","","","","","","","inpatient","","","19204.79","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3412.00","","Per diem ($3,412). If length of stay < 15.26, first 1 days paid at a per diem of $6,824 instead.","50556.95","50556.95","50556.95","1 through 10","1361","246674.36","per diem","Estimated amount calculated based on 6 day length of stay."
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","49645.90","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","5716.5934","","Fee schedule rate ($105,650.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5716.5934","110680.75","110680.75","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","39802.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","44886.97","","Standard inlier is a Case rate ($44,886.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,371.88) for the length of stay and the standard reimbursement.","44886.96","44886.96","44886.96","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","39802.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","48217.55","","Standard inlier is a Case rate ($48,217.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,844.28) for the length of stay and the standard reimbursement.","46025.84","46025.84","46025.84","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","39802.97","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","5444.4012","","Fee schedule rate ($39,078.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5444.4012","39078.14","39078.14","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","39802.97","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","89207.13","","Fee schedule rate ($89,207.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","86609.66","86609.66","86609.66","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4449.47","","Standard inlier is a Case rate ($4,449.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $16,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($631.62) for the length of stay and the standard reimbursement.","4449.47","4449.47","4449.47","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4779.62","","Standard inlier is a Case rate ($4,779.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $16,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($678.45) for the length of stay and the standard reimbursement.","4562.36","4562.36","4779.62","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","5444.4012","","Fee schedule rate ($5,444.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5444.4012","5444.40","5444.40","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","5716.5934","","Fee schedule rate ($5,716.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5716.5934","5716.60","5716.60","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","5988.79","","Fee schedule rate ($5,988.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5988.80","5988.80","5988.80","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","MASSHEALTH [3001]","HB NWH MEDICAID","3143.79","","Case rate ($3,386.94). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,816.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4244.57","4244.57","4244.57","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","5400.03","","Fee schedule rate ($5,400.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4449.21","4449.21","4449.21","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","13540.96","","Fee schedule rate ($13,540.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13540.96","13540.96","13540.96","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","5026.39","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3143.79","","Case rate ($3,386.94). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $45,816.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4244.56","4244.56","4244.56","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","7217.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12647.29","","Standard inlier is a Case rate ($12,647.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,795.33) for the length of stay and the standard reimbursement.","12647.28","12647.28","12647.28","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","7217.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13585.71","","Standard inlier is a Case rate ($13,585.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,928.43) for the length of stay and the standard reimbursement.","13585.71","13585.71","13585.71","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","7217.83","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","5716.5934","","Fee schedule rate ($17,794.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5716.5934","16946.82","16946.82","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","7217.83","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","18641.33","","Fee schedule rate ($18,641.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18641.33","18641.33","18641.33","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","7217.83","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","19477.00","","Fee schedule rate ($19,477.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6885.97","6885.97","6885.97","1 through 10","3143.79","166021.13","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MAJOR","639","DRG","","","","","","","","inpatient","","","4346.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","36873.01","","Fee schedule rate ($36,873.01). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,265.63) multiplied by length of stay and the outlier percent (100%).","9165.98","9165.98","9165.98","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8232.14","","Standard inlier is a Case rate ($8,232.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,094, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,168.58) for the length of stay and the standard reimbursement.","8232.13","7858.39","8232.13","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8842.96","","Standard inlier is a Case rate ($8,842.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,094, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,255.22) for the length of stay and the standard reimbursement.","8842.95","8441.00","8842.95","25","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3255.6972","","Fee schedule rate ($10,681.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3255.6972","9606.84","9606.84","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9606.8472","","Fee schedule rate ($10,681.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9606.8472","9606.84","9606.84","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11749.71","","Fee schedule rate ($11,749.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10567.44","10567.44","10567.44","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","MASSHEALTH [3001]","HB NWH MEDICAID","4921.31","","Case rate ($5,301.94). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,731.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6644.46","6644.46","6644.46","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","8320.14","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","20759.69","","Fee schedule rate ($20,759.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20759.69","20759.69","20759.69","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11259.74","","Standard inlier is a Case rate ($11,259.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,199, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,598.36) for the length of stay and the standard reimbursement.","10748.66","10748.07","10804.92","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12095.21","","Standard inlier is a Case rate ($12,095.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,199, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,716.86) for the length of stay and the standard reimbursement.","11546.59","11545.42","12095.20","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10087.1404","","Fee schedule rate ($26,013.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10087.1404","27252.63","27252.63","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3418.4654","","Fee schedule rate ($26,013.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3418.4654","27252.63","27252.63","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","MASSHEALTH [3001]","HB NWH MEDICAID","11577.88","","Case rate ($12,473.34). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,903.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15631.76","16229.76","16229.76","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","28226.78","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","37468.47","","Fee schedule rate ($37,468.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37468.47","37468.47","37468.47","1 through 10","2673.93","40878.94","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","12078.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","95566.09","","Standard inlier is a Case rate ($95,566.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $102,917, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,565.20) for the length of stay and the standard reimbursement.","91222.17","91222.17","91222.17","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","30599.62","","Standard inlier is a Case rate ($30,599.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,343.74) for the length of stay and the standard reimbursement.","30599.62","30548.73","45950.83","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","32870.10","","Standard inlier is a Case rate ($32,870.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,665.77) for the length of stay and the standard reimbursement.","31379.97","31376.00","32870.09","18","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14189.4462","","Fee schedule rate ($38,527.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14189.4462","38527.06","38527.06","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","14898.8459","","Fee schedule rate ($40,453.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14898.8459","42379.36","42379.36","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","42379.36","","Fee schedule rate ($42,379.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42379.36","42379.36","42379.36","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","MASSHEALTH [3001]","HB NWH MEDICAID","19584.72","","Case rate ($21,099.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,529.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26442.14","26442.14","26442.14","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","27040.76","","Fee schedule rate ($27,040.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22757.64","22757.64","22757.64","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","28391.59","","Fee schedule rate ($28,391.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","55957.87","55957.87","55957.87","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","57636.07","","Fee schedule rate ($57,636.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57636.07","57065.76","57636.07","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","29916.65","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","19584.72","","Case rate ($21,099.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,529.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26442.13","26442.13","26442.13","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","15920.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14191.39","","Standard inlier is a Case rate ($14,191.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,014.41) for the length of stay and the standard reimbursement.","14191.39","14191.39","14191.39","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","634","DRG","","","","","","","","inpatient","","","9901.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29109.60","","Standard inlier is a Case rate ($29,109.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,449, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,131.99) for the length of stay and the standard reimbursement.","27786.43","27786.43","27786.43","1 through 10","7890.18","95566.09","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6219.46","","Standard inlier is a Case rate ($6,219.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($882.88) for the length of stay and the standard reimbursement.","6219.45","5936.83","6219.45","12","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6680.94","","Standard inlier is a Case rate ($6,680.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($948.33) for the length of stay and the standard reimbursement.","6680.93","6377.25","6680.93","36","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3255.6972","","Fee schedule rate ($10,681.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3255.6972","10681.66","10681.66","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3418.4654","","Fee schedule rate ($11,215.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3418.4654","10783.32","15891.89","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11749.71","","Fee schedule rate ($11,749.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11749.71","11749.71","11749.71","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","MASSHEALTH [3001]","HB NWH MEDICAID","4195.91","","Case rate ($4,520.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,950.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5665.07","5665.07","5665.07","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5265.34","","Fee schedule rate ($5,265.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5265.34","5265.34","5265.34","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11222.81","","Fee schedule rate ($11,222.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11222.81","10896.03","11222.81","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","8798.24","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","3581.2336","","Fee schedule rate ($11,749.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3581.2336","6330.30","6330.30","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2601.04","","Standard inlier is a Case rate ($2,601.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $14,316, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($369.23) for the length of stay and the standard reimbursement.","2601.04","2482.84","2601.04","269","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2794.04","","Standard inlier is a Case rate ($2,794.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $14,316, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($396.60) for the length of stay and the standard reimbursement.","2794.03","2667.03","2794.03","784","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","2673.93","","Fee schedule rate ($3,315.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.471), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($28,489), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2673.93","3203.61","3203.61","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3255.6972","","Fee schedule rate ($3,255.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3255.6972","3130.24","3255.70","137","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3418.4654","","Fee schedule rate ($3,418.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3418.4654","3286.68","3829.22","94","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","4069.54","","Fee schedule rate ($4,069.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4069.54","4069.54","4069.54","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","3581.23","","Fee schedule rate ($3,581.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3581.23","3443.12","3581.24","61","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","3418.47","","Fee schedule rate ($3,418.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3418.47","3418.47","3418.47","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","MASSHEALTH [3001]","HB NWH MEDICAID","1562.76","","Case rate ($1,683.62). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $44,113.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2109.95","2109.95","2109.95","163","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","1147.24","","Fee schedule rate ($1,147.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1147.23","1147.23","1147.23","14","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1349.68","","Fee schedule rate ($1,349.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1349.68","1310.38","1349.68","40","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","1417.11","","Fee schedule rate ($1,417.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1417.11","1417.11","1417.11","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2876.79","","Fee schedule rate ($2,876.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2876.79","2793.02","2876.79","80","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","4069.5382","","Fee schedule rate ($4,069.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4069.5382","3912.77","3912.77","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","4747.64","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","3581.2336","","Fee schedule rate ($3,581.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3581.2336","3443.12","3443.12","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3441.91","","Standard inlier is a Case rate ($3,441.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $15,179, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($488.59) for the length of stay and the standard reimbursement.","3441.90","3285.50","3441.90","70","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3697.29","","Standard inlier is a Case rate ($3,697.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $15,179, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($524.82) for the length of stay and the standard reimbursement.","3697.29","3529.23","3697.29","143","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3255.6972","","Fee schedule rate ($4,695.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3255.6972","4695.94","4695.94","22","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3418.4654","","Fee schedule rate ($4,930.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3418.4654","4930.72","4930.72","15","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","5869.81","","Fee schedule rate ($5,869.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5869.81","5869.81","5869.81","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","5165.49","","Fee schedule rate ($5,165.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5165.49","4966.28","5165.49","12","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","MASSHEALTH [3001]","HB NWH MEDICAID","1990.00","","Case rate ($2,143.91). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $44,573.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2686.78","2686.78","2686.78","39","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","1808.90","","Fee schedule rate ($1,808.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1808.89","1808.89","1808.89","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2128.11","","Fee schedule rate ($2,128.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2128.11","2066.14","2128.11","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","2234.42","","Fee schedule rate ($2,234.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2128.11","2128.11","2128.11","1 through 10","1147.24","17624.57","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","5166.80","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4535.96","","Fee schedule rate ($4,535.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4535.96","4403.88","4535.96","17","1147.24","17624.57","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","18425.63","","MASSHEALTH [3001]","HB NWH MEDICAID","65817.42","","Case rate ($70,907.88). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $113,337.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,005.88 and the sum of the standard inlier and any outlier amount.","2363.15","2363.15","2363.15","1 through 10","1818","229042.03","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MAJOR","611","DRG","","","","","","","","inpatient","","","83089.59","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61460.5607","","Fee schedule rate ($119,584.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61460.5607","45989.92","45989.92","1 through 10","18069.95","187918.03","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MINOR","611","DRG","","","","","","","","inpatient","","","1963.00","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61460.5607","","Fee schedule rate ($61,460.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61460.5607","61460.56","61460.56","1 through 10","18069.95","187918.03","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","34074.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22876.35","","Standard inlier is a Case rate ($22,876.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,247.20) for the length of stay and the standard reimbursement.","21836.51","21836.51","21836.51","1 through 10","15421.94","173495.29","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","34074.95","","MASSHEALTH [3001]","HB NWH MEDICAID","15421.94","","Case rate ($16,614.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,044.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20821.79","20821.79","20821.79","1 through 10","15421.94","173495.29","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","99164.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","51731.55","","Standard inlier is a Case rate ($51,731.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $64,719, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,343.50) for the length of stay and the standard reimbursement.","51731.55","51731.55","51731.55","1 through 10","15421.94","173495.29","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","99164.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","55570.01","","Standard inlier is a Case rate ($55,570.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $64,719, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,887.93) for the length of stay and the standard reimbursement.","55570.00","55570.00","55570.00","1 through 10","15421.94","173495.29","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","78317.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","117602.38","","Standard inlier is a Case rate ($117,602.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $123,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,693.16) for the length of stay and the standard reimbursement.","117602.37","117602.37","117602.37","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","78317.44","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","69027.9679","","Fee schedule rate ($119,246.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69027.9679","22929.86","22929.86","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","78317.44","","MASSHEALTH [3001]","HB NWH MEDICAID","60891.53","","Case rate ($65,601.01). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $108,031.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","63484.28","63484.28","63484.28","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","78317.44","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","146980.35","","Fee schedule rate ($146,980.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","146980.35","146980.35","146980.35","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","78317.44","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","72314.6936","","Fee schedule rate ($124,924.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72314.6936","79361.28","79361.28","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","612","DRG","","","","","","","","inpatient","","","78056.82","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","91070.87","","Standard inlier is a Case rate ($91,070.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $98,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,927.13) for the length of stay and the standard reimbursement.","91070.87","91070.87","91070.87","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","612","DRG","","","","","","","","inpatient","","","78056.82","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","43455.05","","Fee schedule rate ($43,455.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43454.72","43454.72","43454.72","1 through 10","42822.73","187386.01","case rate",""
"Neonate Birth Weight 1500-2499 Grams With Major Procedure,MAJOR","609","DRG","","","","","","","","inpatient","","","19963.73","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","86823.1518","","Fee schedule rate ($147,119.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","86823.1518","147120.00","147120.00","1 through 10","37362.67","242745.73","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,MODERATE","623","DRG","","","","","","","","inpatient","","","16397.30","","MASSHEALTH [3001]","HB NWH MEDICAID","24732.22","","Case rate ($26,645.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,075.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,004.90 and the sum of the standard inlier and any outlier amount.","22613.08","22613.08","22613.08","1 through 10","1775","37244.18","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,MODERATE","623","DRG","","","","","","","","inpatient","","","16397.30","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","24732.22","","Case rate ($26,645.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,075.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,004.90 and the sum of the standard inlier and any outlier amount.","60822.77","60822.77","60822.77","1 through 10","1775","37244.18","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MAJOR","621","DRG","","","","","","","","inpatient","","","20427.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31523.84","","Standard inlier is a Case rate ($31,523.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,986, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,474.93) for the length of stay and the standard reimbursement.","74966.87","74966.87","74966.87","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MAJOR","621","DRG","","","","","","","","inpatient","","","20427.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20290.4586","","Fee schedule rate ($65,792.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20290.4586","65792.06","65792.06","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","46235.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10454.60","","Standard inlier is a Case rate ($10,454.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,633, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,483.99) for the length of stay and the standard reimbursement.","10454.59","10454.59","10454.59","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","46235.47","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","22319.30","","Fee schedule rate ($22,319.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22319.28","22319.28","22319.28","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","46235.47","","MASSHEALTH [3001]","HB NWH MEDICAID","8655.71","","Case rate ($9,325.16). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,755.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11686.42","11686.42","11686.42","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MODERATE","621","DRG","","","","","","","","inpatient","","","37340.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31523.84","","Standard inlier is a Case rate ($31,523.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,986, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,474.93) for the length of stay and the standard reimbursement.","31523.83","31523.83","31523.83","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MODERATE","621","DRG","","","","","","","","inpatient","","","37340.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","33862.89","","Standard inlier is a Case rate ($33,862.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,986, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,806.69) for the length of stay and the standard reimbursement.","33862.89","33862.89","33862.89","1 through 10","8655.71","132549.59","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MAJOR","625","DRG","","","","","","","","inpatient","","","94789.47","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29846.4966","","Fee schedule rate ($61,658.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29846.4966","61658.92","61658.92","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","60906.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24698.86","","Standard inlier is a Case rate ($24,698.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,506.10) for the length of stay and the standard reimbursement.","24698.86","24698.86","24698.86","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","60906.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26531.51","","Standard inlier is a Case rate ($26,531.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,766.04) for the length of stay and the standard reimbursement.","26531.50","25325.52","26531.50","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","60906.19","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29846.4966","","Fee schedule rate ($29,846.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29846.4966","29846.50","29846.50","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","60906.19","","MASSHEALTH [3001]","HB NWH MEDICAID","17199.46","","Case rate ($18,529.71). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $60,959.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23221.70","23221.70","23221.70","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","67153.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","33585.55","","Standard inlier is a Case rate ($33,585.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,767.60) for the length of stay and the standard reimbursement.","33585.55","33585.55","33585.55","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","67153.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36077.58","","Standard inlier is a Case rate ($36,077.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,121.06) for the length of stay and the standard reimbursement.","34437.69","34437.69","34437.69","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","67153.32","","MASSHEALTH [3001]","HB NWH MEDICAID","20699.67","","Case rate ($22,300.63). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $64,730.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29016.60","29016.60","29016.60","1 through 10","17033.85","101736.27","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","58706.07","","Standard inlier is a Case rate ($58,706.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $71,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,333.56) for the length of stay and the standard reimbursement.","58706.07","56038.37","58706.07","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","63062.03","","Standard inlier is a Case rate ($63,062.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $71,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,951.39) for the length of stay and the standard reimbursement.","63062.02","63062.02","63062.02","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29846.4966","","Fee schedule rate ($66,745.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29846.4966","66745.70","66745.70","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","31564.2384","","Fee schedule rate ($66,745.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31564.2384","66745.70","66745.70","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","31338.6687","","Fee schedule rate ($70,082.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31338.6687","67380.98","67380.98","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","33142.2888","","Fee schedule rate ($70,082.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33142.2888","67380.98","67380.98","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","MASSHEALTH [3001]","HB NWH MEDICAID","35002.09","","Case rate ($37,709.23). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $80,139.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17710.59","17710.59","17710.59","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","87711.87","","Fee schedule rate ($87,711.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","85157.94","85157.94","85157.94","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","87682.94","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","35002.09","","Case rate ($37,709.23). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $80,139.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","66906.76","66906.76","66906.76","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","622","DRG","","","","","","","","inpatient","","","100214.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","55606.87","","Standard inlier is a Case rate ($55,606.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $64,753, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,893.16) for the length of stay and the standard reimbursement.","53079.28","53079.28","53079.28","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","622","DRG","","","","","","","","inpatient","","","100214.04","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","68899.02","","Fee schedule rate ($68,899.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68899.02","68899.02","68899.02","1 through 10","20342.17","110129.38","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","13473.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10325.72","","Standard inlier is a Case rate ($10,325.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,465.78) for the length of stay and the standard reimbursement.","9856.50","9856.50","10325.71","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","13473.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11091.88","","Standard inlier is a Case rate ($11,091.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,574.45) for the length of stay and the standard reimbursement.","10587.70","10587.70","11091.88","12","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","13473.87","","MASSHEALTH [3001]","HB NWH MEDICAID","8865.90","","Case rate ($9,551.61). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,981.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11970.22","11970.22","11970.22","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","13473.87","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25834.21","","Fee schedule rate ($25,834.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25834.21","25834.21","25834.21","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3738.54","","Standard inlier is a Case rate ($3,738.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $15,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($530.70) for the length of stay and the standard reimbursement.","3568.65","3568.65","3738.53","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4015.94","","Standard inlier is a Case rate ($4,015.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $15,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($570.05) for the length of stay and the standard reimbursement.","4015.93","3833.39","4015.93","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3834.1404","","Fee schedule rate ($3,834.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3834.1404","3834.14","3834.14","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","4025.8278","","Fee schedule rate ($4,025.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4025.8278","4025.84","4025.84","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","4217.52","","Fee schedule rate ($4,217.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4054.87","4054.87","4054.87","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","MASSHEALTH [3001]","HB NWH MEDICAID","2189.92","","Case rate ($2,359.29). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $44,789.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2956.69","2956.69","2956.69","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","4735.55","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2426.29","","Fee schedule rate ($2,426.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","1310.38","1310.38","1310.38","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","5833.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4361.22","","Standard inlier is a Case rate ($4,361.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($619.09) for the length of stay and the standard reimbursement.","4361.21","4361.21","4361.21","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","5833.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4684.82","","Standard inlier is a Case rate ($4,684.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($664.99) for the length of stay and the standard reimbursement.","4684.81","4471.87","4684.81","11","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","5833.84","","MASSHEALTH [3001]","HB NWH MEDICAID","3504.78","","Case rate ($3,775.85). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,205.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4731.94","4731.94","4731.94","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","5833.84","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4329.97","","Fee schedule rate ($4,329.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4203.89","4203.89","4203.89","1 through 10","2062.36","40814.46","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","5833.84","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9229.13","","Fee schedule rate ($9,229.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9229.13","9229.13","9229.13","1 through 10","2062.36","40814.46","case rate",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4989.65","3742.24","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","12531.35","","Case rate ($12,787.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,135.81, add-ons for qualifying new technology services are included. If operating cost exceeds $58,278.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,919.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,809.91. The transfer operating threshold is the transfer adjustment factor * $13,135.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $977.18. The transfer capital threshold is the transfer adjustment factor * $977.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14235.32","14235.32","14235.32","1 through 10","12531.35","14598.1418","other","Inpatient DRG"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Major Problem","790","TRIS-DRG","","","","","","","","inpatient","","","4563.80","","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","5377.69","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,539.85). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $51,361.29 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($3,590.40), capped at $6,798.78. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $51,361.29 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","13599.60","13599.60","13599.60","1 through 10","5377.69","5377.69","other","Inpatient DRGs"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Minor Problem","791","TRIS-DRG","","","","","","","","inpatient","","","32264.55","","TRICARE [160005]","HB NWH TRICARE","2054.66","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($2,880.76). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,702.20 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($2,304.60), capped at $2,597.62. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,702.20 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","3615.25","3615.25","3615.25","1 through 10","2054.66","2054.66","other","Inpatient DRGs"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Other Problem","792","TRIS-DRG","","","","","","","","inpatient","","","4603.14","","TRICARE [160005]","HB NWH TRICARE","1567.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($2,198.36). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,019.80 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,998.51), capped at $1,982.29. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,019.80 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","2699.41","2699.41","2699.41","1 through 10","1567.95","1567.95","other","Inpatient DRGs"
"Neonate, Birth Weight 2000-2499 Grams, Without Significant O.R. Procedures, With Other Problem","680","TRIS-DRG","","","","","","","","inpatient","","","7007.36","","TRICARE [160005]","HB NWH TRICARE","6961.82","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($9,760.88). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,582.33 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($3,200.29), capped at $8,801.52. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,582.33 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","5552.04","5552.04","5552.04","1 through 10","6961.82","6961.82","other","Inpatient DRGs"
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9590.27","","Standard inlier is a Case rate ($9,590.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,487, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,361.38) for the length of stay and the standard reimbursement.","2519.37","2519.37","2519.37","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10301.86","","Standard inlier is a Case rate ($10,301.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,487, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,462.31) for the length of stay and the standard reimbursement.","1395.80","1395.80","1395.80","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2796.4602","","Fee schedule rate ($8,848.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2796.4602","8848.62","8848.62","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","11060.55","","Fee schedule rate ($11,060.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11060.55","11060.55","11060.55","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","9733.39","","Fee schedule rate ($9,733.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9733.39","9733.39","9733.39","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","MASSHEALTH [3001]","HB NWH MEDICAID","3688.70","","Case rate ($3,973.99). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,403.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,779.01 and the sum of the standard inlier and any outlier amount.","3482.70","3482.70","3482.70","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","16320.68","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3612.00","","Per diem ($3,612). If length of stay < 1.38, first 1 days paid at a per diem of $7,224 instead.","3611.89","3611.89","3611.89","1 through 10","871","14600.08","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","5856.82","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5731.61","","Standard inlier is a Case rate ($5,731.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $17,529, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($813.62) for the length of stay and the standard reimbursement.","776.68","776.68","776.68","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","5856.82","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6156.89","","Standard inlier is a Case rate ($6,156.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $17,529, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($873.94) for the length of stay and the standard reimbursement.","3495.77","873.94","3495.77","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","5856.82","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4427.00","","Per diem ($4,427). If length of stay < 1.37, first 1 days paid at a per diem of $8,854 instead.","4426.77","4426.77","4426.77","1 through 10","871","14600.08","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","3969.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2495.63","","Standard inlier is a Case rate ($2,495.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $14,209, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($354.26) for the length of stay and the standard reimbursement.","354.26","354.26","354.26","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","3969.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2680.80","","Standard inlier is a Case rate ($2,680.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $14,209, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($380.53) for the length of stay and the standard reimbursement.","363.22","363.22","363.22","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","3969.67","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2936.2689","","Fee schedule rate ($2,936.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2936.2689","2823.08","2823.08","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","3969.67","","MASSHEALTH [3001]","HB NWH MEDICAID","1928.31","","Case rate ($2,077.45). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $44,507.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,452.76 and the sum of the standard inlier and any outlier amount.","1820.63","1820.63","1820.63","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","3969.67","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2183.00","","Per diem ($2,183). If length of stay < 1.29, first 1 days paid at a per diem of $4,366 instead.","2183.39","2183.39","2183.39","1 through 10","871","14600.08","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","6709.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4015.94","","Standard inlier is a Case rate ($4,015.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $15,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($570.05) for the length of stay and the standard reimbursement.","570.04","570.04","2280.18","1 through 10","871","14600.08","case rate",""
"Neonate, Transferred <5 Days Old","611","TRIS-DRG","","","","","","","","inpatient","","","32536.12","","TRICARE [160005]","HB NWH TRICARE","1969.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($2,761.98). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,583.43 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,603.31), capped at $2,490.52. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $46,583.43 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","2498.90","2498.90","2498.90","1 through 10","1969.95","1969.95","other","Inpatient DRGs"
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","13.33","131.1","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","77.45","77.45","157.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","61.05","61.05","61.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","13.33","131.1","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","77.45","77.45","157.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","61.05","61.05","61.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephritis And Nephrosis,MAJOR","462","DRG","","","","","","","","inpatient","","","40049.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27339.13","","Standard inlier is a Case rate ($27,339.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,694, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,880.90) for the length of stay and the standard reimbursement.","26096.79","26096.79","26096.79","1 through 10","7886.97","36490.53","case rate",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","1384.00","1038.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","1384.00","1038.00","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","16","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","1384.00","1038.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.92","617.92","617.92","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","574.09","617.52","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","outpatient","","","1384.00","1038.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","820.71","59.3","","788.76","788.76","788.76","1 through 10","615.19","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","outpatient","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.19","44.45","","613.24","613.24","613.24","1 through 10","615.19","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","outpatient","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1085.75","78.45","","1034.81","1034.81","1034.81","1 through 10","615.19","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","1384.00","1038.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","1384.00","1038.00","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","620.04","620.04","620.04","1 through 10","474.64","1771","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","outpatient","","","1384.00","1038.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","820.71","59.3","","788.76","788.76","788.76","1 through 10","615.19","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","outpatient","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1085.75","78.45","","1034.80","1034.80","1034.80","1 through 10","615.19","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","774.00","580.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","774.00","580.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","774.00","580.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","336.72","336.72","336.72","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","outpatient","","","774.00","580.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","458.98","59.3","","441.26","441.26","441.26","1 through 10","344.04","623.21","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","outpatient","","","774.00","580.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","607.20","78.45","","578.91","578.91","578.91","1 through 10","344.04","623.21","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","774.00","580.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","774.00","580.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","23","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","774.00","580.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.81","362.81","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","774.00","580.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.42","337.09","362.42","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1018.00","763.50","AETNA [1001]","HB CH AETNA HMO / PPO","593.49","58.3","","561.33","561.33","561.33","1 through 10","351.32","981.49","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1018.00","763.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","30","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1018.00","763.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.41","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1018.00","763.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.62","362.92","1 through 10","351.32","981.49","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","outpatient","","","1018.00","763.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","603.67","59.3","","580.14","580.14","580.14","1 through 10","416.64","1061.72","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","859.00","644.25","AETNA [1001]","HB CH AETNA HMO / PPO","500.80","58.3","","473.45","473.45","473.45","1 through 10","455.27","1771","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","859.00","644.25","MEDICARE [2001]","HB NWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","594.88","630.12","21","455.27","1771","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","859.00","644.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","617.52","617.52","1 through 10","455.27","1771","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","outpatient","","","859.00","644.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","509.39","59.3","","489.31","489.31","489.31","1 through 10","381.83","1132.52","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","outpatient","","","859.00","644.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","673.89","78.45","","641.95","641.95","641.95","1 through 10","381.83","1132.52","percent of total billed charges",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","51292.87","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15125.508","","Fee schedule rate ($33,055.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15125.508","33055.30","33055.30","1 through 10","8387.25","54540.73","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","51292.87","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","14395.18","","Fee schedule rate ($14,395.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13710.28","13710.28","13710.28","1 through 10","8387.25","54540.73","case rate",""
"Nervous System Malignancy,MODERATE","041","DRG","","","","","","","","inpatient","","","20109.90","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15125.508","","Fee schedule rate ($17,746.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15125.508","17746.10","17746.10","1 through 10","8387.25","54540.73","case rate",""
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","42895.04","32171.28","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13228.95","","Case rate ($13,228.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,589.72, add-ons for qualifying new technology services are included. If operating cost exceeds $58,731.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,952.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,218.01. The transfer operating threshold is the transfer adjustment factor * $13,589.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,010.94. The transfer capital threshold is the transfer adjustment factor * $1,010.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12931.32","12931.32","12931.32","1 through 10","12964.37","14824.5999","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","42895.04","32171.28","MEDICARE [2001]","HB NWH MEDICARE","13228.95","","Case rate ($13,228.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,589.72, add-ons for qualifying new technology services are included. If operating cost exceeds $58,731.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,952.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,218.01. The transfer operating threshold is the transfer adjustment factor * $13,589.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,010.94. The transfer capital threshold is the transfer adjustment factor * $1,010.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14333.39","14333.39","14333.39","1 through 10","12964.37","14824.5999","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","42895.04","32171.28","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12964.37","","Case rate ($13,228.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,589.72, add-ons for qualifying new technology services are included. If operating cost exceeds $58,731.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,952.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,218.01. The transfer operating threshold is the transfer adjustment factor * $13,589.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,010.94. The transfer capital threshold is the transfer adjustment factor * $1,010.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9586.56","9586.56","12815.61","1 through 10","12964.37","14824.5999","other","Inpatient DRG"
"Nervous System Neoplasms Without McC","055","MS-DRG","","","","","","","","inpatient","","","26589.26","19941.94","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9712.92","","Case rate ($9,712.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,074.65, add-ons for qualifying new technology services are included. If operating cost exceeds $54,216.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,617.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,037.85. The transfer operating threshold is the transfer adjustment factor * $9,074.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.07. The transfer capital threshold is the transfer adjustment factor * $675.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9408.19","9408.19","9408.19","1 through 10","8657.07","10466.19","other","Inpatient DRG"
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","262.65","196.99","WELLPOINT [1015]","HB CH WELLPOINT","204.63","77.91","","352.06","352.06","352.06","1 through 10","116.75","204.63","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","206.05","78.45","","201.93","201.93","201.93","1 through 10","131.33","206.05","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","both","","","1808.00","1356.00","AETNA [1001]","HB CH AETNA HMO / PPO","1054.06","58.3","","936.24","936.24","936.24","1 through 10","113.91","1719.41","percent of total billed charges",""
"Neurological Eye Disorders","123","MS-DRG","","","","","","","","inpatient","","","34815.72","26111.79","MEDICARE [2001]","HB NWH MEDICARE","6919.01","","Case rate ($6,919.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,107.70, add-ons for qualifying new technology services are included. If operating cost exceeds $52,249.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,470.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,390.27. The transfer operating threshold is the transfer adjustment factor * $7,107.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.74. The transfer capital threshold is the transfer adjustment factor * $528.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7679.66","7679.66","7679.66","1 through 10","6780.63","7950.756","other","Inpatient Replacement Plans DRG"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5343.00","4007.25","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","5081.19","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5343.00","4007.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2676.84","50.1","","2255.00","204.62","2255.00","1 through 10","567.68","4191.58","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5343.00","4007.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4191.58","78.45","","1733.64","1733.64","1733.64","1 through 10","567.68","4191.58","percent of total billed charges",""
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","both","","","4905.00","3678.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2281.93","2281.93","2281.93","1 through 10","1468.33","3821.49","other","OPPS APC"
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","outpatient","","","4905.00","3678.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1468.33","","Case rate ($1,468.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5786.42","5786.42","5786.42","1 through 10","1468.33","4472.66","other","Multiple Surgery"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","29390.92","22043.19","MEDICARE [2001]","HB NWH MEDICARE","1177.88","","Case rate ($1,177.88) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9251.38","9251.38","9251.38","1 through 10","1177.88","9513.218","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","29390.92","22043.19","MOLINA [1014]","HB NWH MEDICARE","1177.88","","Case rate ($1,177.88) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","26340.51","26340.51","26340.51","1 through 10","1177.88","9513.218","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","29390.92","22043.19","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1177.88","","Case rate ($1,177.88) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","830.50","830.50","830.50","1 through 10","1177.88","9513.218","other","Inpatient Psych"
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","975.00","731.25","AETNA [1001]","HB CH AETNA HMO / PPO","568.43","58.3","","3969.00","3969.00","3969.00","1 through 10","516.75","759.62","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","975.00","731.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","578.18","59.3","","2051.00","2051.00","2051.00","1 through 10","433.39","764.89","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.89","78.45","","1813.99","1594.60","2690.80","1 through 10","433.39","764.89","percent of total billed charges",""
"NEUROSTIMULATOR NON-RECHARGEABLE","SUP-ITM-10295658","CDM","C1767","HCPCS","0278","RC","","","","both","","","23268.00","17451.00","AETNA [1001]","HB CH AETNA HMO / PPO","13565.24","58.3","","41334.30","41334.30","41334.30","1 through 10","12332.04","18128.1","percent of total billed charges",""
"NEUROSTIMULATOR NON-RECHARGEABLE","SUP-ITM-10295658","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","23268.00","17451.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","13797.92","59.3","","21359.70","21359.70","21359.70","1 through 10","10342.63","18253.75","percent of total billed charges",""
"NEUROSTIMULATOR NON-RECHARGEABLE","SUP-ITM-10295658","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","23268.00","17451.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18253.75","78.45","","28022.76","16606.62","28022.76","1 through 10","10342.63","18253.75","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE MRI INTERSTIM MICRO SURESCAN BOWEL BLADDER CONTROL","SUP-ITM-10277210","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","22450.00","16837.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17612.03","78.45","","17259.56","17259.56","17259.56","1 through 10","9979.03","17612.03","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","16.57","131.1","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","1 through 10","17.44","108.26","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","103.02","103.02","1 through 10","17.44","108.26","percent of total billed charges",""
"New Patient Psych (99201) – Low Level (< 20 Min)","PX-90000094","CDM","99201","CPT","0914","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","40.21","40.21","40.21","1 through 10","47.6","344","percent of total billed charges",""
"New Pt - Low Level Visit (99201)","PX-51000075","CDM","99201","CPT","0510","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","40.21","40.21","40.21","1 through 10","47.6","93.36","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","both","","","184.00","138.00","AETNA [1001]","HB CH AETNA HMO / PPO","107.27","58.3","","101.49","101.49","101.49","1 through 10","81.79","174.98","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","115.00","62.5","","343.68","114.56","343.68","1 through 10","81.79","174.98","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","outpatient","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","90.29","49.07","","90.36","90.36","90.36","1 through 10","73.6","144.35","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","outpatient","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","92.18","50.1","","106.16","92.26","113.49","1 through 10","73.6","144.35","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","144.35","78.45","","137.62","137.62","137.62","1 through 10","73.6","144.35","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","1515.00","1136.25","AETNA [1001]","HB CH AETNA HMO / PPO","883.25","58.3","","835.19","835.19","835.19","1 through 10","125.72","1439.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","1515.00","1136.25","WELLPOINT [1015]","HB CH WELLPOINT","1180.34","77.91","","1160.13","1160.13","1160.13","1 through 10","125.72","1439.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","1515.00","1136.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","898.40","59.3","","863.18","863.18","863.18","1 through 10","324.44","1188.52","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","1515.00","1136.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1188.52","78.45","","1132.44","671.10","1132.44","1 through 10","324.44","1188.52","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","AETNA [1001]","HB CH AETNA HMO / PPO","299.08","58.3","","282.93","282.93","658.29","91","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","369.87","72.1","","376.25","376.25","875.39","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","325.24","63.4","","330.84","330.84","1161.00","35","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","TRICARE [160005]","HB NWH TRICARE","487.35","95","","171.87","171.87","171.87","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","487.35","95","","142.63","142.63","142.63","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.03","44.45","","383.63","227.34","383.63","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","WELLPOINT [1015]","HB CH WELLPOINT","399.68","77.91","","393.01","393.01","914.40","35","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","304.21","59.3","","292.41","292.41","680.35","97","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","296.00","57.7","","700.08","300.90","1338.63","215","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","310.37","60.5","","707.05","315.87","1405.97","100","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","310.37","60.5","","303.89","303.89","303.89","1 through 10","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.45","78.45","","528.95","227.34","892.58","77","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","both","","","2097.00","1572.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1511.94","72.1","","1675.50","1675.50","1675.50","1 through 10","408.44","1994.25","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","both","","","2097.00","1572.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1329.50","63.4","","1475.44","1475.44","1475.44","1 through 10","408.44","1994.25","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","both","","","2097.00","1572.75","TRICARE [160005]","HB NWH TRICARE","1992.15","95","","502.22","502.22","502.22","1 through 10","408.44","1994.25","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1243.52","59.3","","2097.00","1228.12","6259.90","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","1268.69","60.5","","1354.57","1354.57","1354.57","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1645.10","78.45","","1612.17","955.39","1612.18","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","298.00","223.50","AETNA [1001]","HB CH AETNA HMO / PPO","173.73","58.3","","164.43","74.28","164.43","1 through 10","70.75","383.33","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","298.00","223.50","TRICARE [160005]","HB NWH TRICARE","283.10","95","","290.00","290.00","290.00","1 through 10","70.75","383.33","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","298.00","223.50","WELLPOINT [1015]","HB CH WELLPOINT","232.17","77.91","","228.40","228.40","228.40","1 through 10","70.75","383.33","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","outpatient","","","298.00","223.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","176.71","59.3","","169.94","169.94","169.94","1 through 10","109.07","244","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","outpatient","","","298.00","223.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","233.78","78.45","","222.95","132.12","222.95","1 through 10","109.07","244","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","AETNA [1001]","HB CH AETNA HMO / PPO","278.67","58.3","","271.03","271.03","271.03","24","103.06","477.81","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","344.64","72.1","","573.41","478.00","573.41","1 through 10","103.06","477.81","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","303.05","63.4","","478.00","226.87","504.95","1 through 10","103.06","477.81","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","TRICARE [160005]","HB NWH TRICARE","454.10","95","","171.87","171.87","171.87","1 through 10","103.06","477.81","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.47","44.45","","217.78","217.78","217.78","1 through 10","103.06","477.81","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","inpatient","","","478.00","358.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","267.68","56","","264.29","264.29","264.29","1 through 10","267.68","337.47","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","234.55","49.07","","221.08","221.08","221.08","43","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","239.48","50.1","","221.08","221.08","221.08","79","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.45","59.3","","280.11","280.11","1494.89","45","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","275.81","57.7","","459.30","440.76","459.30","33","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","289.19","60.5","","478.00","478.00","1434.00","1 through 10","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","289.19","60.5","","463.58","463.58","463.58","1 through 10","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","374.99","78.45","","367.49","217.78","367.49","28","174.95","374.99","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","1760.00","1320.00","AETNA [1001]","HB CH AETNA HMO / PPO","1026.08","58.3","","970.14","970.14","970.14","1 through 10","764.84","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","1760.00","1320.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1924.78","1924.78","1924.78","1 through 10","764.84","1627.62","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","1760.00","1320.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1044.03","1043.63","1044.03","1 through 10","764.84","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1797.37","1797.37","1797.37","1 through 10","764.84","1873.9","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1889.15","1889.15","1889.15","1 through 10","764.84","1873.9","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","1760.00","1320.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,682). Procedure 2, Per diem ($1,341). Procedures 3 - 9999, Per diem ($670.50).","2682.00","2682.00","2682.00","1 through 10","755.04","4462.84","per diem",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","1760.00","1320.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1462.38","1462.38","1462.38","1 through 10","755.04","4462.84","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","outpatient","","","1760.00","1320.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1855.11","1855.11","1894.47","1 through 10","1311.96","3485.45","other","ASC "
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","outpatient","","","1760.00","1320.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1857.74","1857.74","1857.74","1 through 10","1311.96","3485.45","other","ASC "
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","369.00","276.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4123.91","4123.91","4123.91","1 through 10","195.57","11465.07","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","369.00","276.75","MEDICARE [2001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","195.57","11465.07","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","369.00","276.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4107.15","4107.15","4107.15","1 through 10","195.57","11465.07","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","outpatient","","","369.00","276.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4765.79","4765.79","4765.79","1 through 10","164.02","7279.88","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","AETNA [1001]","HB CH AETNA HMO / PPO","1051.73","58.3","","994.52","994.52","994.52","1 through 10","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","847.06","847.06","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1550.92","1550.92","1 through 10","598.81","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1404.20","1702.00","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1819.93","1799.29","1877.00","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","TRICARE [160005]","HB NWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","598.81","1627.62","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","813.76","813.76","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.97","739.68","813.47","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","968.26","968.26","988.81","1 through 10","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","969.63","990.18","19","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1069.77","59.3","","1027.84","1027.84","1027.84","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","1407.20","13","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1425.17","1760.50","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1415.24","78.45","","1348.48","1348.48","1713.58","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB CH AETNA HMO / PPO","325.31","58.3","","994.52","994.52","994.52","1 through 10","248.03","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","847.06","847.06","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1550.92","1550.92","1 through 10","248.03","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1404.20","1702.00","1 through 10","248.03","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1819.93","1799.29","1877.00","1 through 10","248.03","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","TRICARE [160005]","HB NWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","248.03","1627.62","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","813.76","813.76","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.97","739.68","813.47","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","330.89","59.3","","1027.84","1027.84","1027.84","1 through 10","277.49","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","1407.20","13","277.49","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1425.17","1760.50","1 through 10","277.49","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","437.75","78.45","","1348.48","1348.48","1713.58","1 through 10","277.49","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB CH AETNA HMO / PPO","1068.64","58.3","","1010.39","1010.39","1010.39","20","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","846.26","846.26","847.99","14","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","19","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","ELDER SERVICES [1037]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 389%, 194.5 procedures at 0%.","1795.54","1795.54","1795.54","1 through 10","598.81","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1491.04","1550.92","1 through 10","598.81","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MEDICARE [2001]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1702.00","1702.00","1702.00","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1866.67","1822.00","5620.66","34","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MOLINA [1014]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1631.66","1631.66","1631.66","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","811.36","805.96","813.36","30","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","805.96","813.87","30","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","968.26","968.26","988.81","49","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","969.63","969.63","990.18","109","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.97","59.3","","1044.25","1044.25","1044.25","12","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","4221.60","57","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1425.17","1479.06","18","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1437.99","78.45","","1370.00","1370.00","1370.00","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB CH AETNA HMO / PPO","300.83","58.3","","1010.39","1010.39","1010.39","20","229.36","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","846.26","846.26","847.99","14","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","19","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","ELDER SERVICES [1037]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 389%, 194.5 procedures at 0%.","1795.54","1795.54","1795.54","1 through 10","229.36","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1491.04","1550.92","1 through 10","229.36","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MEDICARE [2001]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1652.00","1702.00","1 through 10","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1702.00","1702.00","1702.00","1 through 10","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1866.67","1822.00","5620.66","34","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MOLINA [1014]","HB NWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1631.66","1631.66","1631.66","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","811.36","805.96","813.36","30","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","805.96","813.87","30","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","305.99","59.3","","1044.25","1044.25","1044.25","12","256.61","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","4221.60","57","256.61","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1425.17","1479.06","18","256.61","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","404.80","78.45","","1370.00","1370.00","1370.00","1 through 10","256.61","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn","PX-76002391","CDM","62322","CPT","0761","RC","","","","outpatient","","","2252.00","1689.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1335.44","59.3","","1283.34","1283.34","1283.34","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn","PX-98301326","CDM","62322","CPT","0983","RC","","","","outpatient","","","439.00","329.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","260.33","59.3","","1283.34","1283.34","1283.34","1 through 10","195.14","1873.9","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.46","470.46","470.46","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","472.66","472.66","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","outpatient","","","2239.00","1679.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1756.50","78.45","","991.84","991.84","991.84","1 through 10","626.57","1756.5","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","477.20","43","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.46","470.46","1411.38","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","467.86","467.66","470.66","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","1608.00","1206.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","953.54","59.3","","916.50","894.61","1789.22","1 through 10","626.57","1261.48","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","1608.00","1206.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1261.48","78.45","","1202.40","1202.40","1202.40","1 through 10","626.57","1261.48","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","AETNA [1001]","HB CH AETNA HMO / PPO","1108.87","58.3","","1048.38","1048.38","1048.38","1 through 10","453.34","1388.46","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","442.95","469.56","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","59","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","469.66","469.16","470.46","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.66","234.03","472.66","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1127.89","59.3","","1083.51","1083.51","1083.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1492.12","78.45","","1849.00","813.23","2287.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","2755.00","2066.25","MEDICARE [2001]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","2011.15","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","2755.00","2066.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1633.72","59.3","","1569.89","1569.89","1569.89","1 through 10","807.41","2161.3","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","2755.00","2066.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2161.30","78.45","","1220.55","1220.55","1220.55","1 through 10","807.41","2161.3","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","MEDICARE [2001]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1502.00","1126.50","AETNA [1001]","HB CH AETNA HMO / PPO","875.67","58.3","","828.39","828.39","828.39","1 through 10","607.27","1712.76","percent of total billed charges",""
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1502.00","1126.50","MEDICARE [2001]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","outpatient","","","1502.00","1126.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1178.32","78.45","","1461.00","1461.00","1461.00","1 through 10","667.64","1458.24","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","319.68","629.00","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","HUMANA [1012]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.28","630.28","630.28","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","MEDICARE [2001]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","25","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","627.95","627.95","627.95","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","581.13","581.13","581.13","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","outpatient","","","1876.00","1407.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1112.47","59.3","","1068.86","1068.86","1068.86","1 through 10","807.41","1471.72","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","outpatient","","","1876.00","1407.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","833.88","44.45","","1402.29","1402.29","1402.29","1 through 10","807.41","1471.72","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","outpatient","","","1876.00","1407.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1471.72","78.45","","1402.29","831.01","1402.29","1 through 10","807.41","1471.72","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1525.53","1525.53","28","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","HUMANA [1012]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1521.33","1519.33","1521.33","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","MEDICARE [2001]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","379","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","MOLINA [1014]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3075.87","1550.34","3075.87","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.13","1519.33","1524.33","44","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.34","1519.34","1524.34","34","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1860.23","44.45","","1853.84","1853.84","1853.84","1 through 10","1472.82","4622.47","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","4185.00","3138.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2481.71","59.3","","2384.43","2384.43","2384.43","13","2092.5","3721.34","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","4185.00","3138.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3283.13","78.45","","3128.25","1853.84","4365.86","17","2092.5","3721.34","percent of total billed charges",""
"NM Parathyroid Planar","PX-34000005","CDM","78070","CPT","0341","RC","","","","both","","","973.00","729.75","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","1988.00","1491.00","MEDICARE [2001]","HB NWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","1988.00","1491.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","626.45","626.45","626.45","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1512.00","1134.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1512.00","1134.00","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","12","453.34","1329.12","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1512.00","1134.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1417.98","470.46","1417.98","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","outpatient","","","1512.00","1134.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","896.62","59.3","","861.42","861.42","861.42","1 through 10","626.57","1186.16","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","outpatient","","","1512.00","1134.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1186.16","78.45","","669.73","669.73","1130.14","1 through 10","626.57","1186.16","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1307.00","980.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","654.81","50.1","","248.00","248.00","248.00","1 through 10","560.7","1873.9","percent of total billed charges",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","119028.04","89271.03","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","31292.37","","Case rate ($31,292.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,145.76, add-ons for qualifying new technology services are included. If operating cost exceeds $77,288.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,333.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $28,901.04. The transfer operating threshold is the transfer adjustment factor * $32,145.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.33. The transfer capital threshold is the transfer adjustment factor * $2,391.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30911.66","30911.66","30911.66","1 through 10","30666.52","35448.1094","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","119028.04","89271.03","MEDICARE [2001]","HB NWH MEDICARE","31292.37","","Case rate ($31,292.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,145.76, add-ons for qualifying new technology services are included. If operating cost exceeds $77,288.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,333.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $28,901.04. The transfer operating threshold is the transfer adjustment factor * $32,145.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.33. The transfer capital threshold is the transfer adjustment factor * $2,391.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34212.03","34212.03","34212.03","1 through 10","30666.52","35448.1094","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","119028.04","89271.03","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","30666.52","","Case rate ($31,292.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,145.76, add-ons for qualifying new technology services are included. If operating cost exceeds $77,288.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,333.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $28,901.04. The transfer operating threshold is the transfer adjustment factor * $32,145.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,391.33. The transfer capital threshold is the transfer adjustment factor * $2,391.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","40826.64","40826.64","40826.64","1 through 10","30666.52","35448.1094","other","Inpatient DRG"
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,EXTREME","050","DRG","","","","","","","","inpatient","","","119028.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","87163.08","","Standard inlier is a Case rate ($87,163.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $101,068, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,373.14) for the length of stay and the standard reimbursement.","69730.46","69730.46","69730.46","1 through 10","12476.92","163922.05","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MODERATE","050","DRG","","","","","","","","inpatient","","","17414.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26829.22","","Standard inlier is a Case rate ($26,829.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,171, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,808.51) for the length of stay and the standard reimbursement.","26829.21","26829.21","26829.21","1 through 10","12476.92","163922.05","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MAJOR","323","DRG","","","","","","","","inpatient","","","95388.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","60015.17","","Standard inlier is a Case rate ($60,015.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $73,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,519.39) for the length of stay and the standard reimbursement.","57287.98","57287.98","57287.98","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MAJOR","323","DRG","","","","","","","","inpatient","","","95388.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","64468.27","","Standard inlier is a Case rate ($64,468.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $73,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,151.00) for the length of stay and the standard reimbursement.","61537.88","64468.26","64468.26","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","50936.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","40158.02","","Standard inlier is a Case rate ($40,158.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $52,844, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,700.59) for the length of stay and the standard reimbursement.","40158.02","40158.02","40158.02","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","50936.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","43137.73","","Standard inlier is a Case rate ($43,137.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $52,844, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,123.22) for the length of stay and the standard reimbursement.","43137.72","41184.99","43137.72","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","50936.87","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","15978.27","","Case rate ($17,214.07). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $59,644.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17258.34","17258.34","17258.34","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MODERATE","323","DRG","","","","","","","","inpatient","","","79908.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","45092.89","","Standard inlier is a Case rate ($45,092.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,907, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,401.11) for the length of stay and the standard reimbursement.","43043.79","43043.79","43043.79","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MODERATE","323","DRG","","","","","","","","inpatient","","","79908.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","48438.76","","Standard inlier is a Case rate ($48,438.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,907, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,875.68) for the length of stay and the standard reimbursement.","48438.75","48438.75","48438.75","1 through 10","15978.27","64468.27","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MINOR","325","DRG","","","","","","","","inpatient","","","50368.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","49897.83","","Standard inlier is a Case rate ($49,897.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $62,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,083.19) for the length of stay and the standard reimbursement.","47630.39","47630.39","47630.39","1 through 10","31498.46","82356.95","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MINOR","325","DRG","","","","","","","","inpatient","","","50368.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","53600.22","","Standard inlier is a Case rate ($53,600.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $62,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,608.33) for the length of stay and the standard reimbursement.","51174.89","51174.89","53600.22","1 through 10","31498.46","82356.95","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MODERATE","325","DRG","","","","","","","","inpatient","","","78630.43","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","62395.78","","Standard inlier is a Case rate ($62,395.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $71,237, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,856.82) for the length of stay and the standard reimbursement.","62395.78","62395.78","62395.78","1 through 10","31498.46","82356.95","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","68746.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","89119.52","","Standard inlier is a Case rate ($89,119.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $96,759, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,650.14) for the length of stay and the standard reimbursement.","35528.63","35528.63","35528.63","1 through 10","5542.76","217853.36","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","39671.92","","MASSHEALTH [3001]","HB NWH MEDICAID","23314.55","","Case rate ($25,117.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $67,547.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25182.34","25182.34","25182.34","1 through 10","5542.76","217853.36","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","39671.92","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","23314.55","","Case rate ($25,117.74). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $67,547.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5542.76","217853.36","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","19320.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15800.40","","Standard inlier is a Case rate ($15,800.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,242.80) for the length of stay and the standard reimbursement.","30357.95","30357.95","30357.95","1 through 10","5542.76","217853.36","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","19320.40","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15127.4622","","Fee schedule rate ($24,472.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15127.4622","24472.44","24472.44","1 through 10","5542.76","217853.36","case rate",""
"Non-Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","794","DRG","","","","","","","","inpatient","","","43454.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28124.71","","Standard inlier is a Case rate ($28,124.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,507, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,992.18) for the length of stay and the standard reimbursement.","21093.53","21093.53","21093.53","1 through 10","9095.01","28124.71","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","44463.74","33347.80","MEDICARE [2001]","HB NWH MEDICARE","14240.04","","Case rate ($14,240.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,628.38, add-ons for qualifying new technology services are included. If operating cost exceeds $59,770.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,030.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,151.82. The transfer operating threshold is the transfer adjustment factor * $14,628.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,088.21. The transfer capital threshold is the transfer adjustment factor * $1,088.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16377.79","16377.79","16407.23","1 through 10","13955.24","16871.55","other","Inpatient Replacement Plans DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","44463.74","33347.80","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13955.24","","Case rate ($14,240.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,628.38, add-ons for qualifying new technology services are included. If operating cost exceeds $59,770.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,030.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,151.82. The transfer operating threshold is the transfer adjustment factor * $14,628.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,088.21. The transfer capital threshold is the transfer adjustment factor * $1,088.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14637.49","14637.49","14647.05","1 through 10","13955.24","16871.55","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","44463.74","33347.80","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13955.24","","Case rate ($14,240.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,628.38, add-ons for qualifying new technology services are included. If operating cost exceeds $59,770.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,030.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,151.82. The transfer operating threshold is the transfer adjustment factor * $14,628.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,088.21. The transfer capital threshold is the transfer adjustment factor * $1,088.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14664.55","14664.55","14664.55","1 through 10","13955.24","16871.55","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","79971.92","59978.94","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","30594.50","","Case rate ($29,703.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $30,513.46, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,211.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,433.50. The transfer operating threshold is the transfer adjustment factor * $30,513.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,269.90. The transfer capital threshold is the transfer adjustment factor * $2,269.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","31396.56","31396.56","31396.56","1 through 10","29109.33","34638.2003","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","79971.92","59978.94","MEDICARE [2001]","HB NWH MEDICARE","32659.63","","Case rate ($32,659.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $30,513.46, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,211.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,389.73. The transfer operating threshold is the transfer adjustment factor * $30,513.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,269.90. The transfer capital threshold is the transfer adjustment factor * $2,269.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33490.48","33490.48","33490.48","1 through 10","29109.33","34638.2003","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","79971.92","59978.94","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","29109.33","","Case rate ($29,703.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $30,513.46, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,211.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,433.50. The transfer operating threshold is the transfer adjustment factor * $30,513.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,269.90. The transfer capital threshold is the transfer adjustment factor * $2,269.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29862.77","29862.77","29862.77","1 through 10","29109.33","34638.2003","other","Inpatient DRG"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","AETNA [1001]","HB CH AETNA HMO / PPO","0.58","58.3","","0.57","0.57","0.57","66","0.21","33.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB CH WELLPOINT","0.78","77.91","","0.79","0.79","0.79","14","0.21","33.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.59","59.3","","462.94","205.69","1501.32","1 through 10","0.19","21.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","10.30","","APC Price ($10). Final payment is multiplied by 103%.","10.29","6.18","10.32","42","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","10.00","","APC Price ($10).","9.84","5.90","9.84","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MEDICARE [2001]","HB NWH MEDICARE","10.00","","APC Price ($10).","10.00","6.00","10.00","767","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MOLINA [1014]","HB NWH MEDICARE","10.00","","APC Price ($10).","11.91","6.00","11.91","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","17.64","104","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","9.80","70","9.5","10.3","other","OPPS APC"
"Non-Hypovolemic Sodium Disorders,EXTREME","426","DRG","","","","","","","","inpatient","","","78550.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40796.63","","Standard inlier is a Case rate ($40,796.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $50,609, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,790.91) for the length of stay and the standard reimbursement.","33165.27","33165.27","33165.27","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","25309.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21421.21","","Standard inlier is a Case rate ($21,421.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,040.82) for the length of stay and the standard reimbursement.","21421.20","21421.20","21421.20","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","25309.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23010.65","","Standard inlier is a Case rate ($23,010.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,266.26) for the length of stay and the standard reimbursement.","21964.71","21964.71","21964.71","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","25309.76","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9902.91","","Fee schedule rate ($9,902.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9902.91","9902.91","9902.91","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MINOR","426","DRG","","","","","","","","inpatient","","","11880.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11063.62","","Standard inlier is a Case rate ($11,063.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,570.52) for the length of stay and the standard reimbursement.","10561.72","10561.72","10561.72","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MINOR","426","DRG","","","","","","","","inpatient","","","11880.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11884.53","","Standard inlier is a Case rate ($11,884.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,686.96) for the length of stay and the standard reimbursement.","11884.53","11884.53","11884.53","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","29688.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14655.07","","Standard inlier is a Case rate ($14,655.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,681, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,080.34) for the length of stay and the standard reimbursement.","14655.06","14655.06","14655.06","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","29688.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15742.47","","Standard inlier is a Case rate ($15,742.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,681, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,234.58) for the length of stay and the standard reimbursement.","15742.46","15742.46","15742.46","1 through 10","2137","40796.63","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","29688.97","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6950.87","","Fee schedule rate ($6,950.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6950.87","6950.87","6950.87","1 through 10","2137","40796.63","case rate",""
"Non-India Ink (Spot) Tattooing Lymph Node Area","PX-76002699","CDM","38999","CPT","0761","RC","","","","outpatient","","","766.00","574.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.93","78.45","","389.01","389.01","389.01","1 through 10","375.88","970.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","287.00","215.25","AETNA [1001]","HB CH AETNA HMO / PPO","167.32","58.3","","158.19","3.66","158.19","1 through 10","67.25","745.32","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","163.49","163.49","163.49","1 through 10","143.5","473.25","percent of total billed charges",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MAJOR","046","DRG","","","","","","","","inpatient","","","35524.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23858.00","","Standard inlier is a Case rate ($23,858.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,386.74) for the length of stay and the standard reimbursement.","23857.99","23857.99","23857.99","1 through 10","5032.12","35013.76","case rate",""
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","34517.17","25887.88","MEDICARE [2001]","HB NWH MEDICARE","15681.70","","Case rate ($15,681.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,109.37, add-ons for qualifying new technology services are included. If operating cost exceeds $61,251.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,140.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,483.33. The transfer operating threshold is the transfer adjustment factor * $16,109.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,198.38. The transfer capital threshold is the transfer adjustment factor * $1,198.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19006.01","19006.01","19006.01","1 through 10","15368.07","18579.65","other","Inpatient Replacement Plans DRG"
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","34517.17","25887.88","MOLINA [1014]","HB NWH MEDICARE","15681.70","","Case rate ($15,681.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,109.37, add-ons for qualifying new technology services are included. If operating cost exceeds $61,251.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,140.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,483.33. The transfer operating threshold is the transfer adjustment factor * $16,109.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,198.38. The transfer capital threshold is the transfer adjustment factor * $1,198.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2987.45","2987.45","2987.45","1 through 10","15368.07","18579.65","other","Inpatient Replacement Plans DRG"
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","34517.17","25887.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","15368.07","","Case rate ($15,681.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,109.37, add-ons for qualifying new technology services are included. If operating cost exceeds $61,251.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,140.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,483.33. The transfer operating threshold is the transfer adjustment factor * $16,109.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,198.38. The transfer capital threshold is the transfer adjustment factor * $1,198.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16977.38","16977.38","16977.38","1 through 10","15368.07","18579.65","other","Inpatient DRG"
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","34517.17","25887.88","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15368.07","","Case rate ($15,681.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,109.37, add-ons for qualifying new technology services are included. If operating cost exceeds $61,251.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,140.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,483.33. The transfer operating threshold is the transfer adjustment factor * $16,109.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,198.38. The transfer capital threshold is the transfer adjustment factor * $1,198.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16983.36","16983.36","16983.36","1 through 10","15368.07","18579.65","other","Inpatient DRG"
"Normal Newborn","795","TRIS-DRG","","","","","","","","inpatient","","","4581.83","","CHAMPVA [160001]","HB NWH TRICARE","950.32","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($1,332.40). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $45,153.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,567.53), capped at $1,201.45. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $45,153.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","4840.85","4840.85","4840.85","1 through 10","950.32","950.32","other","Inpatient DRGs"
"Normal Newborn","795","TRIS-DRG","","","","","","","","inpatient","","","4581.83","","TRICARE [160005]","HB NWH TRICARE","950.32","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($1,332.40). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $45,153.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,567.53), capped at $1,201.45. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $45,153.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","1537.93","1537.93","1537.93","1 through 10","950.32","950.32","other","Inpatient DRGs"
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","34","34.39","207.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","186.00","139.50","CHAMPVA [160001]","HB NWH TRICARE","176.70","95","","181.00","181.00","181.00","1 through 10","34.39","207.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB NWH TRICARE","176.70","95","","42.28","42.28","42.28","1 through 10","34.39","207.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","82.46","82.46","139.15","1 through 10","34.39","207.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","106.07","33","26.86","164.21","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","82.46","139.15","41","26.86","164.21","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","243.00","182.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.10","59.3","","491.61","138.30","491.61","1 through 10","26.86","190.63","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","190.63","78.45","","181.44","107.52","181.44","1 through 10","26.86","190.63","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","91","34.39","285.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","TRICARE [160005]","HB NWH TRICARE","285.95","95","","42.28","42.28","42.28","1 through 10","34.39","285.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","285.95","95","","35.09","35.09","35.09","1 through 10","34.39","285.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.79","44.45","","225.26","133.49","225.26","1 through 10","34.39","285.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","171.70","95","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","171.70","1 through 10","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","78","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB CH AETNA HMO / PPO","123.60","58.3","","116.80","116.80","116.80","529","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","154.76","73","","150.38","150.38","150.38","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","154.76","73","","116.80","116.80","116.80","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","TRICARE [160005]","HB NWH TRICARE","201.40","95","","42.28","40.17","42.28","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","201.40","95","","35.09","35.09","125.55","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.23","44.45","","158.37","93.85","158.38","21","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.72","59.3","","120.72","120.72","362.16","561","26.86","166.31","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","166.31","78.45","","158.37","93.85","158.38","491","26.86","166.31","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TRICARE [160005]","HB NWH TRICARE","219.45","95","","84.56","11.75","84.56","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","219.45","95","","125.55","125.55","125.55","1 through 10","34.39","219.45","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","468.69","26","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","17","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Myco Pneum","PX-30001327","CDM","87581","CPT","0306","RC","","","","both","","","239.00","179.25","AETNA [1001]","HB CH AETNA HMO / PPO","139.34","58.3","","131.54","131.54","131.54","1 through 10","34.39","227.05","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB CH AETNA HMO / PPO","123.60","58.3","","116.80","116.80","116.80","522","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","154.76","73","","150.38","150.38","150.38","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","154.76","73","","116.80","116.80","116.80","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","TRICARE [160005]","HB NWH TRICARE","201.40","95","","42.28","40.17","42.28","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","201.40","95","","35.09","35.09","125.55","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.23","44.45","","158.37","93.85","158.37","21","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.72","59.3","","120.72","120.72","362.16","560","26.86","166.31","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","166.31","78.45","","158.37","93.85","158.37","487","26.86","166.31","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","222.00","166.50","AETNA [1001]","HB CH AETNA HMO / PPO","129.43","58.3","","122.47","122.47","244.94","36","36.52","210.9","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","222.00","166.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.65","59.3","","126.58","126.58","126.58","39","26.86","174.16","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.16","78.45","","166.06","98.41","166.06","17","26.86","174.16","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","245.00","183.75","AETNA [1001]","HB CH AETNA HMO / PPO","142.84","58.3","","134.95","134.95","134.95","1 through 10","34.39","232.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","226.00","169.50","AETNA [1001]","HB CH AETNA HMO / PPO","131.76","58.3","","124.74","124.74","124.74","36","34.39","214.7","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","226.00","169.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.46","44.45","","100.23","100.23","100.23","1 through 10","34.39","214.7","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","226.00","169.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.02","59.3","","128.92","128.92","131.79","30","26.86","177.3","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","226.00","169.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","177.30","78.45","","169.14","100.23","389.14","32","26.86","177.3","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","285.95","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","171.70","1 through 10","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Genotype Hepatitis C","PX-30001361","CDM","87902","CPT","0306","RC","","","","both","","","1302.00","976.50","AETNA [1001]","HB CH AETNA HMO / PPO","759.07","58.3","","717.82","717.82","717.82","1 through 10","252.3","1518.93","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","175.20","175.20","175.20","1 through 10","41.98","302.1","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","140.78","140.78","237.56","13","41.98","302.1","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","500.24","180.96","543.21","1 through 10","44.17","270.03","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","237.56","237.56","237.56","1 through 10","44.17","270.03","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","356.00","267.00","AETNA [1001]","HB CH AETNA HMO / PPO","207.55","58.3","","196.18","196.18","196.18","12","41.98","338.2","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","356.00","267.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","211.11","59.3","","202.76","202.76","608.28","15","44.17","279.28","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","279.28","78.45","","266.00","137.91","266.01","1 through 10","44.17","279.28","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","138","19.65","118.31","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","both","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.45","44.45","","88.41","52.39","88.41","1 through 10","19.65","118.31","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","202.17","119","20.68","126.38","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","88.41","134","20.68","126.38","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","501.00","375.75","AETNA [1001]","HB CH AETNA HMO / PPO","292.08","58.3","","276.13","276.13","276.13","1 through 10","41.98","475.95","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","501.00","375.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","297.09","59.3","","285.38","285.38","285.38","1 through 10","44.17","393.03","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","393.03","78.45","","374.40","221.88","374.40","1 through 10","44.17","393.03","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","652.00","489.00","AETNA [1001]","HB CH AETNA HMO / PPO","380.12","58.3","","359.48","359.48","359.48","1 through 10","83.4","619.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","652.00","489.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.64","59.3","","371.52","371.52","371.52","1 through 10","57.95","511.49","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","652.00","489.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","487.42","487.42","487.42","1 through 10","57.95","511.49","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","292.00","219.00","AETNA [1001]","HB CH AETNA HMO / PPO","170.24","58.3","","161.03","161.03","161.03","1 through 10","34.39","277.4","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","243.82","1 through 10","34.39","209.95","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","97.95","97.95","97.95","1 through 10","34.39","209.95","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","26.86","173.37","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","208.11","1 through 10","26.86","173.37","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","AETNA [1001]","HB CH AETNA HMO / PPO","56.30","58.3","","464.71","67.87","1012.10","221","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","56.30","58.3","","293.04","293.04","293.04","11","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.18","53","","983.89","983.89","983.89","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","56.01","58","","677.18","677.18","677.18","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","60.36","62.5","","46.58","46.58","46.58","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","70.50","73","","747.15","747.15","747.15","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.93","44.45","","1141.67","481.21","1141.67","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.93","44.45","","76.54","76.54","76.54","1 through 10","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.57","72.43","WELLPOINT [1015]","HB CH WELLPOINT","75.24","77.91","","273.64","94.28","1367.51","138","42.93","75.24","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.57","72.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","57.27","59.3","","720.78","230.14","2010.94","427","48.29","75.76","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.57","72.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","57.27","59.3","","344.45","344.45","344.45","1 through 10","48.29","75.76","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.57","72.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","75.76","78.45","","1120.13","1120.13","1120.13","1 through 10","48.29","75.76","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.57","72.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.76","78.45","","456.17","105.33","1284.66","242","48.29","75.76","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","AETNA [1001]","HB CH AETNA HMO / PPO","558.00","58.3","","464.71","67.87","1012.10","221","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","558.00","58.3","","293.04","293.04","293.04","11","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","507.27","53","","983.89","983.89","983.89","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","555.13","58","","677.18","677.18","677.18","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","598.20","62.5","","46.58","46.58","46.58","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","698.70","73","","747.15","747.15","747.15","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.44","44.45","","1141.67","481.21","1141.67","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.44","44.45","","76.54","76.54","76.54","1 through 10","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","WELLPOINT [1015]","HB CH WELLPOINT","745.69","77.91","","273.64","94.28","1367.51","138","425.44","745.69","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","567.57","59.3","","720.78","230.14","2010.94","427","478.56","750.86","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","567.57","59.3","","344.45","344.45","344.45","1 through 10","478.56","750.86","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","750.86","78.45","","1120.13","1120.13","1120.13","1 through 10","478.56","750.86","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","750.86","78.45","","456.17","105.33","1284.66","242","478.56","750.86","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","195.62","28","34.1","147.2","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","118.00","88.50","WELLPOINT [1015]","HB CH WELLPOINT","91.93","77.91","","90.58","90.57","90.58","14","34.1","147.2","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","269.56","17","59","140.98","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.40","88.41","39","59","140.98","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","130.41","17","28.81","127.59","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","134.78","1 through 10","52.45","130.05","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.40","88.41","22","52.45","130.05","percent of total billed charges",""
"Nwh Cholesterol on Fluid","PX-30003276","CDM","84999","CPT","0301","RC","","","","outpatient","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.01","78.45","","38.44","38.44","38.44","1 through 10","4.28","40.01","percent of total billed charges",""
"Nwh Kinevac 5 Mcg Vial (Rad)","PX-63600475","CDM","J2805","HCPCS","0636","RC","","","","both","","","292.00","219.00","AETNA [1001]","HB CH AETNA HMO / PPO","170.24","58.3","","107.16","107.16","107.16","1 through 10","154.76","328.23","percent of total billed charges",""
"Nwh Kinevac 5 Mcg Vial (Rad)","PX-63600475","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","292.00","219.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.42","52.2","","105.02","105.02","105.02","1 through 10","146","292.34","percent of total billed charges",""
"Nwh Malaria Antigen Test","PX-30002958","CDM","87899","CPT","0306","RC","","","","both","","","393.00","294.75","AETNA [1001]","HB CH AETNA HMO / PPO","229.12","58.3","","216.59","216.59","216.59","1 through 10","15.75","373.35","percent of total billed charges",""
"Nwh Mayo Medical Labs 89591 Posa Posaconazole Serum","PX-30003029","CDM","80299","CPT","0301","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","121.91","121.91","121.91","1 through 10","18.27","245.1","percent of total billed charges",""
"Nwh Mayo Medical Labs 89591 Posa Posaconazole Serum","PX-30003029","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","125.99","125.99","125.99","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh Mayo Medical Labs 89591 Posa Posaconazole Serum","PX-30003029","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","165.29","97.95","215.00","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh Mml Amio Amiodarone Serum","PX-30002258","CDM","80299","CPT","0301","RC","","","","both","","","56.00","42.00","AETNA [1001]","HB CH AETNA HMO / PPO","32.65","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Mml Amio Amiodarone Serum","PX-30002258","CDM","80299","CPT","0301","RC","","","","outpatient","","","56.00","42.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","33.21","59.3","","125.99","125.99","125.99","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Amio Amiodarone Serum","PX-30002258","CDM","80299","CPT","0301","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","165.29","97.95","215.00","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Bats Testosterone Bioavailable","PX-30003294","CDM","84999","CPT","0301","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","0.78","78.45","","38.44","38.44","38.44","1 through 10","0.49","28.31","percent of total billed charges",""
"Nwh Mml Cital Citalopram Serum","PX-30002264","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","136.8","percent of total billed charges",""
"Nwh Mml Cital Citalopram Serum","PX-30002264","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Cital Citalopram Serum","PX-30002264","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","97.95","215.00","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Faaab","PX-30003052","CDM","80299","CPT","0300","RC","","","","both","","","1065.00","798.75","AETNA [1001]","HB CH AETNA HMO / PPO","620.90","58.3","","121.91","121.91","121.91","1 through 10","18.27","1011.75","percent of total billed charges",""
"Nwh Mml Faaab","PX-30003052","CDM","80299","CPT","0300","RC","","","","outpatient","","","1065.00","798.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","631.55","59.3","","125.99","125.99","125.99","1 through 10","14.12","835.49","percent of total billed charges",""
"Nwh Mml Faaab","PX-30003052","CDM","80299","CPT","0300","RC","","","","outpatient","","","1065.00","798.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","835.49","78.45","","165.29","97.95","215.00","1 through 10","14.12","835.49","percent of total billed charges",""
"Nwh Mml Felba Felbamate (Felbatol) Serum","PX-30002257","CDM","80299","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","121.91","121.91","121.91","1 through 10","18.27","102.6","percent of total billed charges",""
"Nwh Mml Felba Felbamate (Felbatol) Serum","PX-30002257","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","125.99","125.99","125.99","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Felba Felbamate (Felbatol) Serum","PX-30002257","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","165.29","97.95","215.00","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Ffes Estradiol Free, Serum Unlisted Chem","PX-30003059","CDM","84999","CPT","0301","RC","","","","outpatient","","","2.00","1.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1.57","78.45","","38.44","38.44","38.44","1 through 10","0.98","28.31","percent of total billed charges",""
"Nwh Mml Fluox Fluoxetine Serum","PX-30003293","CDM","80299","CPT","0301","RC","","","","both","","","141.00","105.75","AETNA [1001]","HB CH AETNA HMO / PPO","82.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","133.95","percent of total billed charges",""
"Nwh Mml Fluox Fluoxetine Serum","PX-30003293","CDM","80299","CPT","0301","RC","","","","outpatient","","","141.00","105.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.61","59.3","","125.99","125.99","125.99","1 through 10","14.12","110.61","percent of total billed charges",""
"Nwh Mml Fluox Fluoxetine Serum","PX-30003293","CDM","80299","CPT","0301","RC","","","","outpatient","","","141.00","105.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.61","78.45","","165.29","97.95","215.00","1 through 10","14.12","110.61","percent of total billed charges",""
"Nwh Mml Itcon Itraconazole Serum","PX-30002259","CDM","80299","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","121.91","121.91","121.91","1 through 10","18.27","102.6","percent of total billed charges",""
"Nwh Mml Itcon Itraconazole Serum","PX-30002259","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","125.99","125.99","125.99","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Itcon Itraconazole Serum","PX-30002259","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","165.29","97.95","215.00","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Laco Lacosamide Serum","PX-30003007","CDM","80299","CPT","0301","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB CH AETNA HMO / PPO","111.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","182.4","percent of total billed charges",""
"Nwh Mml Laco Lacosamide Serum","PX-30003007","CDM","80299","CPT","0301","RC","","","","outpatient","","","192.00","144.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.86","59.3","","125.99","125.99","125.99","1 through 10","14.12","150.62","percent of total billed charges",""
"Nwh Mml Laco Lacosamide Serum","PX-30003007","CDM","80299","CPT","0301","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.62","78.45","","165.29","97.95","215.00","1 through 10","14.12","150.62","percent of total billed charges",""
"Nwh Mml Mst Drug of Abuse Tetrahydrocannabinol Gc-Ms Conf Urine","PX-30002982","CDM","80299","CPT","0301","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","218.5","percent of total billed charges",""
"Nwh Mml Mst Drug of Abuse Tetrahydrocannabinol Gc-Ms Conf Urine","PX-30002982","CDM","80299","CPT","0301","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","180.44","percent of total billed charges",""
"Nwh Mml Mst Drug of Abuse Tetrahydrocannabinol Gc-Ms Conf Urine","PX-30002982","CDM","80299","CPT","0301","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","97.95","215.00","1 through 10","14.12","180.44","percent of total billed charges",""
"Nwh Mml Mtx Methotrexate Serum","PX-30002983","CDM","80299","CPT","0301","RC","","","","both","","","377.00","282.75","AETNA [1001]","HB CH AETNA HMO / PPO","219.79","58.3","","121.91","121.91","121.91","1 through 10","18.27","358.15","percent of total billed charges",""
"Nwh Mml Mtx Methotrexate Serum","PX-30002983","CDM","80299","CPT","0301","RC","","","","outpatient","","","377.00","282.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.56","59.3","","125.99","125.99","125.99","1 through 10","14.12","295.76","percent of total billed charges",""
"Nwh Mml Mtx Methotrexate Serum","PX-30002983","CDM","80299","CPT","0301","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","165.29","97.95","215.00","1 through 10","14.12","295.76","percent of total billed charges",""
"Nwh Mml Paro Paroxetine Serum","PX-30002260","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","136.8","percent of total billed charges",""
"Nwh Mml Paro Paroxetine Serum","PX-30002260","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Paro Paroxetine Serum","PX-30002260","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","97.95","215.00","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Venla Venlafaxine  Serum","PX-30002261","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","136.8","percent of total billed charges",""
"Nwh Mml Venla Venlafaxine  Serum","PX-30002261","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Venla Venlafaxine  Serum","PX-30002261","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","97.95","215.00","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Vori Voriconazole Serum","PX-30002262","CDM","80299","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","121.91","121.91","121.91","1 through 10","18.27","106.4","percent of total billed charges",""
"Nwh Mml Vori Voriconazole Serum","PX-30002262","CDM","80299","CPT","0301","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","125.99","125.99","125.99","1 through 10","14.12","87.86","percent of total billed charges",""
"Nwh Mml Vori Voriconazole Serum","PX-30002262","CDM","80299","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","165.29","97.95","215.00","1 through 10","14.12","87.86","percent of total billed charges",""
"Nwh Mml Wrf Warfarin Serum","PX-30002263","CDM","80299","CPT","0301","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","121.91","121.91","121.91","1 through 10","18.27","245.1","percent of total billed charges",""
"Nwh Mml Wrf Warfarin Serum","PX-30002263","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","125.99","125.99","125.99","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh Mml Wrf Warfarin Serum","PX-30002263","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","165.29","97.95","215.00","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh Mml Zw230 Ca125 on Body Fluid","PX-30003030","CDM","84999","CPT","0300","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","251.82","78.45","","38.44","38.44","38.44","1 through 10","4.28","251.82","percent of total billed charges",""
"Nwh P Mml Infxr Infliximab Quant W Reflex to Ab to Inliximab, Serum","PX-30003053","CDM","80299","CPT","0301","RC","","","","both","","","409.00","306.75","AETNA [1001]","HB CH AETNA HMO / PPO","238.45","58.3","","121.91","121.91","121.91","1 through 10","18.27","388.55","percent of total billed charges",""
"Nwh P Mml Infxr Infliximab Quant W Reflex to Ab to Inliximab, Serum","PX-30003053","CDM","80299","CPT","0301","RC","","","","outpatient","","","409.00","306.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","242.54","59.3","","125.99","125.99","125.99","1 through 10","14.12","320.86","percent of total billed charges",""
"Nwh P Mml Infxr Infliximab Quant W Reflex to Ab to Inliximab, Serum","PX-30003053","CDM","80299","CPT","0301","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.86","78.45","","165.29","97.95","215.00","1 through 10","14.12","320.86","percent of total billed charges",""
"Nwh Potassium on Fluid","PX-30003277","CDM","84999","CPT","0301","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","38.44","38.44","38.44","1 through 10","4.28","43.93","percent of total billed charges",""
"Nwh Prom Lab 3170 Measure Serum Adalimumab and Ab (Ada & Ata)","PX-30001847","CDM","84999","CPT","0301","RC","","","","outpatient","","","6144.00","4608.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4819.97","78.45","","38.44","38.44","38.44","1 through 10","4.28","4819.97","percent of total billed charges",""
"Nwh Rufinamide, Serum","PX-30003644","CDM","80299","CPT","0301","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Rufinamide, Serum","PX-30003644","CDM","80299","CPT","0301","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","125.99","125.99","125.99","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Rufinamide, Serum","PX-30003644","CDM","80299","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","165.29","97.95","215.00","1 through 10","14.12","86.37","percent of total billed charges",""
"O.R. Procedure For Other Complications Of Treatment,MINOR","791","DRG","","","","","","","","inpatient","","","69007.96","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16331.2494","","Fee schedule rate ($16,331.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16331.2494","13487.88","13487.88","1 through 10","13412.985","45860.64","case rate",""
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","27526.95","20645.21","HUMANA [1012]","HB NWH MEDICARE","13068.66","","Case rate ($13,068.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,425.07, add-ons for qualifying new technology services are included. If operating cost exceeds $58,567.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,940.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,069.97. The transfer operating threshold is the transfer adjustment factor * $13,425.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.69. The transfer capital threshold is the transfer adjustment factor * $998.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23273.47","23273.47","23273.47","1 through 10","12807.29","15483.73","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","27526.95","20645.21","MEDICARE [2001]","HB NWH MEDICARE","13068.66","","Case rate ($13,068.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,425.07, add-ons for qualifying new technology services are included. If operating cost exceeds $58,567.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,940.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,069.97. The transfer operating threshold is the transfer adjustment factor * $13,425.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.69. The transfer capital threshold is the transfer adjustment factor * $998.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13976.76","13976.76","13976.76","1 through 10","12807.29","15483.73","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","27526.95","20645.21","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12807.29","","Case rate ($13,068.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,425.07, add-ons for qualifying new technology services are included. If operating cost exceeds $58,567.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,940.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,069.97. The transfer operating threshold is the transfer adjustment factor * $13,425.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.69. The transfer capital threshold is the transfer adjustment factor * $998.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12476.28","12476.28","12476.28","1 through 10","12807.29","15483.73","other","Inpatient DRG"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC","939","MS-DRG","","","","","","","","inpatient","","","46354.86","34766.14","MEDICARE [2001]","HB NWH MEDICARE","31437.05","","Case rate ($31,437.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $32,294.39, add-ons for qualifying new technology services are included. If operating cost exceeds $77,436.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,344.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $29,034.67. The transfer operating threshold is the transfer adjustment factor * $32,294.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,402.39. The transfer capital threshold is the transfer adjustment factor * $2,402.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30292.79","30292.79","30292.79","1 through 10","30808.31","32380.16","other","Inpatient Replacement Plans DRG"
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","AETNA [1001]","HB CH AETNA HMO / PPO","198.02","58.3","","464.71","67.87","1012.10","221","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.02","58.3","","293.04","293.04","293.04","11","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.02","53","","983.89","983.89","983.89","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","197.00","58","","677.18","677.18","677.18","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","212.29","62.5","","46.58","46.58","46.58","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","247.95","73","","747.15","747.15","747.15","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.98","44.45","","1141.67","481.21","1141.67","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.98","44.45","","76.54","76.54","76.54","1 through 10","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","WELLPOINT [1015]","HB CH WELLPOINT","264.63","77.91","","273.64","94.28","1367.51","138","150.98","264.63","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.42","59.3","","720.78","230.14","2010.94","427","169.83","266.46","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","201.42","59.3","","344.45","344.45","344.45","1 through 10","169.83","266.46","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","266.46","78.45","","1120.13","1120.13","1120.13","1 through 10","169.83","266.46","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.46","78.45","","456.17","105.33","1284.66","242","169.83","266.46","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","148.55","3073","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","123.00","123.00","123.00","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","51.38","7.29","144.52","682","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","93.27","93.27","93.27","72","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","59.68","59.68","59.68","15","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","131.00","222","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","131.00","59.68","131.00","48","95.31","95.31","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","353.80","235.87","786.22","722","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,710).","1211.00","1211.00","1816.50","1 through 10","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","390.42","227.06","1059.71","2573","105.91","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1965.00","1048.00","1965.00","1 through 10","105.91","4642","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","196.17","812","105.91","4642","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3267.18","2450.38","AETNA [1001]","HB CH AETNA HMO / PPO","1904.77","58.3","","1952.48","1215.31","1952.48","1 through 10","1452.26","2545.46","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3267.18","2450.38","WELLPOINT [1015]","HB CH WELLPOINT","2545.46","77.91","","2735.63","2146.75","4736.42","1 through 10","1452.26","2545.46","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3267.18","2450.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","1937.44","59.3","","1597.25","1552.67","1756.87","1 through 10","1633.59","2563.1","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3267.18","2450.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2563.10","78.45","","2647.39","1568.87","3176.87","1 through 10","1633.59","2563.1","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1530.90","1160.93","1884.08","89","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","5253.92","5253.92","5253.92","1 through 10","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","12181.47","12181.47","12181.47","1 through 10","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","1350.68","1350.68","1350.68","1 through 10","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1910.74","891.94","1910.74","1 through 10","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","1829.79","1561.50","2617.12","88","66.68","116.87","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1359.46","1201.30","1689.00","61","75","117.68","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","1718.92","1718.92","1718.92","1 through 10","75","117.68","percent of total billed charges",""
"OCCLUDER APICAL SZ 1 ORIGINAL SIZE","SUP-ITM-10115638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1910.74","1019.06","2344.84","74","75","117.68","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","95.26","95.26","95.26","1 through 10","15.6","164.35","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","1 through 10","15.29","135.72","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","129.16","129.16","1 through 10","15.29","135.72","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","both","","","37.00","27.75","AETNA [1001]","HB CH AETNA HMO / PPO","21.57","58.3","","20.41","20.41","20.41","1 through 10","4.15","35.15","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","outpatient","","","37.00","27.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.94","59.3","","63.30","21.10","63.30","1 through 10","3.36","29.03","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","16.40","27.68","1 through 10","3.36","29.03","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","240.98","240.98","1 through 10","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.06","1 through 10","110.05","415.15","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","240.98","240.98","45","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","319.01","73","","240.98","240.98","240.98","1 through 10","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","TRICARE [160005]","HB NWH TRICARE","415.15","95","","112.30","106.69","112.78","1 through 10","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.96","74","110.05","415.15","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB CH WELLPOINT","340.47","77.91","","334.73","334.73","334.73","18","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","437.00","327.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","259.14","59.3","","248.96","248.96","248.96","1 through 10","218.5","455.7","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","342.83","78.45","","129.57","129.57","129.57","1 through 10","218.5","455.7","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","207.62","240.98","1 through 10","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","TRICARE [160005]","HB NWH TRICARE","415.15","95","","112.30","107.14","112.78","1 through 10","110.05","415.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.93","21","110.05","415.15","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB CH WELLPOINT","340.47","77.91","","334.73","334.73","334.73","1 through 10","110.05","415.15","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","673","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","69.60","58","","24.11","24.11","24.11","80","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.60","58","","28.36","27.54","28.36","249","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","73.08","60.9","","29.78","28.36","29.78","30","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.00","62.5","","31.26","30.35","31.26","626","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","66.35","66.34","114.00","1 through 10","53.34","157.62","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","75.00","75.00","75.00","1 through 10","60","286.15","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","125.87","125.87","125.87","82","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","132.24","58","","181.86","181.86","181.86","1 through 10","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","213.96","207.76","213.96","17","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","138.85","60.9","","213.96","213.96","213.96","1 through 10","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","222.00","222.00","666.00","58","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","125.88","125.88","125.88","1 through 10","101.35","166.44","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","AETNA [1001]","HB CH AETNA HMO / PPO","267.01","58.3","","252.32","252.32","252.32","25","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.64","58","","398.63","398.63","398.63","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.64","58","","445.00","387.06","445.00","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","286.25","62.5","","445.00","445.00","890.00","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","AETNA [1001]","HB CH AETNA HMO / PPO","267.01","58.3","","252.32","252.32","252.32","25","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.64","58","","398.63","398.63","398.63","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.64","58","","445.00","387.06","445.00","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","286.25","62.5","","445.00","445.00","890.00","1 through 10","145.39","334.34","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","AETNA [1001]","HB CH AETNA HMO / PPO","267.01","58.3","","252.32","252.32","252.32","25","145.39","435.56","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","290.37","63.4","","191.54","191.54","191.54","1 through 10","145.39","435.56","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","265.64","58","","398.63","398.63","398.63","1 through 10","145.39","435.56","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","265.64","58","","445.00","387.06","445.00","1 through 10","145.39","435.56","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","286.25","62.5","","445.00","445.00","890.00","1 through 10","145.39","435.56","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","458.00","343.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","271.59","59.3","","260.77","260.77","260.77","1 through 10","79.3","359.3","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","AETNA [1001]","HB CH AETNA HMO / PPO","22.15","58.3","","66.34","66.34","66.34","673","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","22.15","58.3","","66.34","66.34","66.34","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","22.04","58","","24.11","24.11","24.11","80","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","22.04","58","","28.36","27.54","28.36","249","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","23.14","60.9","","29.78","28.36","29.78","30","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23.75","62.5","","31.26","30.35","31.26","626","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","27.74","73","","66.35","66.34","114.00","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","22.53","59.3","","68.56","45.75","304.13","26","22.41","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","29.81","78.45","","75.00","75.00","75.00","1 through 10","22.41","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","AETNA [1001]","HB CH AETNA HMO / PPO","167.32","58.3","","125.87","125.87","125.87","82","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","166.46","58","","181.86","181.86","181.86","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","166.46","58","","213.96","207.76","213.96","17","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","174.78","60.9","","213.96","213.96","213.96","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","179.38","62.5","","222.00","222.00","666.00","58","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","209.51","73","","125.88","125.88","125.88","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","130.09","130.09","130.09","1 through 10","79.3","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","AETNA [1001]","HB CH AETNA HMO / PPO","364.96","58.3","","252.32","252.32","252.32","25","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","363.08","58","","398.63","398.63","398.63","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","363.08","58","","445.00","387.06","445.00","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","391.25","62.5","","445.00","445.00","890.00","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.22","59.3","","260.77","260.77","260.77","1 through 10","79.3","491.1","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","AETNA [1001]","HB CH AETNA HMO / PPO","167.32","58.3","","125.87","125.87","125.87","82","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","166.46","58","","181.86","181.86","181.86","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","166.46","58","","213.96","207.76","213.96","17","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","174.78","60.9","","213.96","213.96","213.96","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","179.38","62.5","","222.00","222.00","666.00","58","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","209.51","73","","125.88","125.88","125.88","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","130.09","130.09","130.09","1 through 10","79.3","245.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","AETNA [1001]","HB CH AETNA HMO / PPO","364.96","58.3","","252.32","252.32","252.32","25","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","363.08","58","","398.63","398.63","398.63","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","363.08","58","","445.00","387.06","445.00","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","391.25","62.5","","445.00","445.00","890.00","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.22","59.3","","260.77","260.77","260.77","1 through 10","79.3","491.1","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","357.00","267.75","AETNA [1001]","HB CH AETNA HMO / PPO","208.13","58.3","","196.75","196.75","196.75","1 through 10","141.78","260.61","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","223.13","62.5","","292.62","284.15","292.62","1 through 10","141.78","260.61","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","both","","","748.00","561.00","AETNA [1001]","HB CH AETNA HMO / PPO","436.08","58.3","","412.21","412.21","412.21","1 through 10","145.39","546.04","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","both","","","748.00","561.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","467.50","62.5","","649.16","649.16","649.16","1 through 10","145.39","546.04","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","748.00","561.00","AETNA [1001]","HB CH AETNA HMO / PPO","436.08","58.3","","412.21","412.21","412.21","1 through 10","145.39","711.35","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","748.00","561.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","467.50","62.5","","649.16","649.16","649.16","1 through 10","145.39","711.35","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB CH AETNA HMO / PPO","239.61","58.3","","196.75","196.75","196.75","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","256.88","62.5","","292.62","284.15","292.62","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","AETNA [1001]","HB CH AETNA HMO / PPO","529.95","58.3","","412.21","412.21","412.21","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","568.13","62.5","","649.16","649.16","649.16","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB CH AETNA HMO / PPO","239.61","58.3","","196.75","196.75","196.75","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","256.88","62.5","","292.62","284.15","292.62","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","AETNA [1001]","HB CH AETNA HMO / PPO","529.95","58.3","","412.21","412.21","412.21","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","568.13","62.5","","649.16","649.16","649.16","1 through 10","147.01","863.55","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","AETNA [1001]","HB CH AETNA HMO / PPO","2434.23","58.3","","464.71","67.87","1012.10","221","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2434.23","58.3","","293.04","293.04","293.04","11","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2212.94","53","","983.89","983.89","983.89","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2421.70","58","","677.18","677.18","677.18","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2609.59","62.5","","46.58","46.58","46.58","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3048.01","73","","747.15","747.15","747.15","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.94","44.45","","1141.67","481.21","1141.67","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.94","44.45","","76.54","76.54","76.54","1 through 10","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","WELLPOINT [1015]","HB CH WELLPOINT","3253.02","77.91","","273.64","94.28","1367.51","138","1855.94","3253.02","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2475.98","59.3","","720.78","230.14","2010.94","427","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2475.98","59.3","","344.45","344.45","344.45","1 through 10","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3275.56","78.45","","1120.13","1120.13","1120.13","1 through 10","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3275.56","78.45","","456.17","105.33","1284.66","242","2087.68","3275.56","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","77.45","77.45","77.45","1 through 10","20.73","137.29","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0250","RC","","","","inpatient","","","12.07","9.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8.52","70.6","","0.30","0.30","0.30","76","5.37","8.52","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","AETNA [1001]","HB CH AETNA HMO / PPO","7.04","58.3","","0.44","0.31","0.46","18007","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.40","53","","16.38","16.38","16.38","1 through 10","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8.81","73","","23.10","23.10","23.10","1 through 10","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","12.07","9.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","6.30","52.2","","0.40","0.04","0.55","458","6.04","6.3","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","AETNA [1001]","HB CH AETNA HMO / PPO","14.71","58.3","","0.01","0.01","0.01","1 through 10","6.18","20.87","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.37","6.37","6.37","100","6.18","20.87","other","OPPS APC"
"Open Extracranial Vascular Procedures,MAJOR","024","DRG","","","","","","","","inpatient","","","52595.49","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","25164.2334","","Fee schedule rate ($75,023.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25164.2334","75023.70","75023.70","1 through 10","8539.19","123787.94","case rate",""
"Open Extracranial Vascular Procedures,MINOR","024","DRG","","","","","","","","inpatient","","","45942.23","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28915.04","","Fee schedule rate ($28,915.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28915.04","28915.04","28915.04","1 through 10","8539.19","123787.94","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","55939.42","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","44752.71","","Fee schedule rate ($44,752.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44752.71","44752.71","44752.71","1 through 10","8539.19","123787.94","case rate",""
"Open Tx Carpal Bone Fracture Oth/Thn Scaphoid Ea","PX-76000468","CDM","25645","CPT","0761","RC","","","","both","","","10170.00","7627.50","AETNA [1001]","HB CH AETNA HMO / PPO","5929.11","58.3","","9375.91","9375.91","9375.91","1 through 10","4362.93","7923.45","percent of total billed charges",""
"Open Tx Distal Fibular Fracture Lat Malleolus","PX-76000615","CDM","27792","CPT","0761","RC","","","","both","","","13868.00","10401.00","AETNA [1001]","HB CH AETNA HMO / PPO","8085.04","58.3","","5601.39","5601.39","5601.39","1 through 10","5129.63","10804.56","percent of total billed charges",""
"Open/Perq Place Stent Same","PX-76001941","CDM","37238","CPT","0761","RC","","","","both","","","16762.00","12571.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13206.16","13206.16","13206.16","1 through 10","8702.14","13870.23","other","OPPS APC"
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.90","0.67","AETNA [1001]","HB CH AETNA HMO / PPO","0.52","58.3","","0.10","0.07","0.12","423","0.19","0.77","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.47","52.2","","0.11","0.08","0.25","366","0.04","0.47","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","20","20.79","181.45","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","191.00","143.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.26","59.3","","109.00","109.00","109.00","12","16.96","149.84","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.84","78.45","","137.25","84.74","143.00","1 through 10","16.96","149.84","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","1 through 10","16.12","169.1","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","both","","","178.00","133.50","TRICARE [160005]","HB NWH TRICARE","169.10","95","","19.82","19.82","19.82","1 through 10","16.12","169.1","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","16.96","139.64","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","78.82","133.00","1 through 10","16.96","139.64","percent of total billed charges",""
"Organic Acids Total Qn","PX-30000590","CDM","83918","CPT","0301","RC","","","","both","","","177.00","132.75","AETNA [1001]","HB CH AETNA HMO / PPO","103.19","58.3","","195.04","195.04","195.04","1 through 10","23.13","168.15","percent of total billed charges",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1309.53","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9541.61","9541.61","9541.61","1 through 10","1247.17","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","332.09","332.09","332.09","1 through 10","1247.17","16515.36","case rate",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","HUMANA [1012]","HB NWH MEDICARE","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14242.10","14242.10","14242.10","1 through 10","1247.17","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","MEDICARE [2001]","HB NWH MEDICARE","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15940.67","6794.94","15969.33","71","1247.17","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","MOLINA [1014]","HB NWH MEDICARE","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","28796.50","28796.50","28796.50","1 through 10","1247.17","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12128.83","43.41","14236.66","1 through 10","1247.17","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","28905.67","21679.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1247.17","","Case rate ($1,247.17) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14241.53","14241.53","14241.53","1 through 10","1247.17","16515.36","other","Inpatient Psych"
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","14","51.33","364.8","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB NWH TRICARE","196.65","95","","52.37","52.37","52.37","1 through 10","51.33","364.8","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","51.33","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($52.38). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($34.76). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","52.24","51.84","52.24","1 through 10","51.33","364.8","fee schedule",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","14","51.33","364.8","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB NWH TRICARE","196.65","95","","52.37","52.37","52.37","1 through 10","51.33","364.8","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","51.33","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($52.38). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($34.76). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","52.24","51.84","52.24","1 through 10","51.33","364.8","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","284.00","213.00","AETNA [1001]","HB CH AETNA HMO / PPO","165.57","58.3","","259.47","259.47","259.47","1 through 10","56.36","364.8","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","284.00","213.00","AETNA [1001]","HB CH AETNA HMO / PPO","165.57","58.3","","259.47","259.47","259.47","1 through 10","56.36","364.8","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","1 through 10","6.48","59.85","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","44.74","44.74","44.74","1 through 10","6.48","59.85","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","130.83","35.74","130.83","1 through 10","6.82","49.42","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","27.79","61.00","1 through 10","6.82","49.42","percent of total billed charges",""
"Osmolality Stool","PX-30001482","CDM","84999","CPT","0300","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","38.44","38.44","38.44","1 through 10","4.28","62.76","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","65.00","48.75","AETNA [1001]","HB CH AETNA HMO / PPO","37.90","58.3","","35.72","35.72","35.72","1 through 10","6.68","61.75","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","65.00","48.75","CHAMPVA [160001]","HB NWH TRICARE","61.75","95","","8.22","8.22","8.22","1 through 10","6.68","61.75","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.89","44.45","","47.01","47.01","47.01","1 through 10","6.68","61.75","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","65.00","48.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.55","59.3","","36.92","36.92","135.12","1 through 10","7.02","50.99","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.99","78.45","","48.43","48.43","126.00","1 through 10","7.02","50.99","percent of total billed charges",""
"Osmolality, Feces","PX-30003319","CDM","84999","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","38.44","38.44","38.44","1 through 10","4.28","46.29","percent of total billed charges",""
"Ossicular Implant T1","PX-27000563","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","801.38","601.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","475.22","59.3","","782.24","782.24","782.24","1 through 10","400.69","628.68","percent of total billed charges",""
"Osteocalcin","PX-30000596","CDM","83937","CPT","0301","RC","","","","outpatient","","","246.00","184.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","145.88","59.3","","140.05","140.05","140.05","1 through 10","30.78","192.99","percent of total billed charges",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","17763.81","13322.86","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11006.43","","Case rate ($11,231.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,537.34, add-ons for qualifying new technology services are included. If operating cost exceeds $56,679.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,800.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,372.78. The transfer operating threshold is the transfer adjustment factor * $11,537.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.27. The transfer capital threshold is the transfer adjustment factor * $858.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11036.82","11036.82","11036.82","1 through 10","11006.43","13306.52","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","31287.94","23465.95","MEDICARE [2001]","HB NWH MEDICARE","18763.76","","Case rate ($18,763.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,530.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,673.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,246.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $17,459.65. The transfer operating threshold is the transfer adjustment factor * $17,530.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,304.12. The transfer capital threshold is the transfer adjustment factor * $1,304.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19336.83","19336.83","19336.83","1 through 10","16724.02","19623.7316","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","31287.94","23465.95","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16724.02","","Case rate ($17,065.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,530.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,673.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,246.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $15,761.22. The transfer operating threshold is the transfer adjustment factor * $17,530.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,304.12. The transfer capital threshold is the transfer adjustment factor * $1,304.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17244.01","17244.01","17244.01","1 through 10","16724.02","19623.7316","other","Inpatient DRG"
"Osteomyelitis Without Cc/McC","541","MS-DRG","","","","","","","","inpatient","","","15234.15","11425.61","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6821.98","","Case rate ($6,821.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,008.02, add-ons for qualifying new technology services are included. If operating cost exceeds $52,150.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,463.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,300.65. The transfer operating threshold is the transfer adjustment factor * $7,008.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.33. The transfer capital threshold is the transfer adjustment factor * $521.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8231.36","8231.36","8231.36","1 through 10","6685.54","8082.66","other","Inpatient Replacement Plans DRG"
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","31108.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","28962.02","","Standard inlier is a Case rate ($28,962.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $41,360, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,111.27) for the length of stay and the standard reimbursement.","28962.02","28962.02","28962.02","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","31108.91","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","54819.50","","Fee schedule rate ($54,819.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29510.47","29510.47","29510.47","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MINOR","344","DRG","","","","","","","","inpatient","","","9196.35","","MASSHEALTH [3001]","HB NWH MEDICAID","7247.17","","Case rate ($7,807.68). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,237.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","153.57","153.57","153.57","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","16236.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20190.55","","Standard inlier is a Case rate ($20,190.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,866.13) for the length of stay and the standard reimbursement.","20190.55","20190.55","20190.55","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","16236.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21688.68","","Standard inlier is a Case rate ($21,688.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,078.62) for the length of stay and the standard reimbursement.","21688.68","21688.68","21688.68","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","16236.83","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17486.1816","","Per diem ($2,993). If length of stay < 8, first 1 days paid at a per diem of $5,986 instead.","17486.1816","23942.86","23942.86","1 through 10","1903","126460.97","per diem","Estimated amount calculated based on 1 day length of stay."
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","16236.83","","MASSHEALTH [3001]","HB NWH MEDICAID","8535.76","","Case rate ($9,195.93). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,625.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,393.32 and the sum of the standard inlier and any outlier amount.","9219.58","9219.58","9219.58","1 through 10","1903","126460.97","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","16236.83","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","2350.00","","Per diem ($2,350). If length of stay < 4.51, first 1 days paid at a per diem of $4,700 instead.","10095.95","10095.95","10095.95","1 through 10","1903","126460.97","per diem","Estimated amount calculated based on 1 day length of stay."
"Ot E-Stim Attended 15 Min","PX-43000017","CDM","97032","CPT","0431","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB NWH TRICARE","97.85","95","","15.74","15.74","15.74","1 through 10","15.37","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","167.51","72.52","167.79","1073","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.86","58.3","","95.26","95.26","95.26","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","51.05","51.05","51.05","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","190.51","115.34","556.99","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB NWH TRICARE","164.35","95","","32.64","32.11","65.28","76","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.45","23.78","32.11","634","31.47","364.8","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","192.19","16","86.5","232","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","77.33","51.22","120.67","1 through 10","86.5","232","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.00","62.78","82.78","30","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","14.18","14.18","14.18","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","TRICARE [160005]","HB NWH TRICARE","142.50","95","","91.51","61.01","91.51","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.79","23.31","26.65","13","31.47","364.8","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","75.57","206.39","24","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","136.51","73","","103.19","103.19","103.19","1 through 10","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB NWH TRICARE","177.65","95","","35.97","34.17","68.34","1 through 10","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.74","28.89","35.27","11","35.26","364.8","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","110.89","59.3","","106.61","106.61","106.61","1 through 10","93.5","251.62","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","66.96","66.96","87.89","315","29.66","364.8","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","116.07","73","","226.30","106.58","226.30","1 through 10","29.66","364.8","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","TRICARE [160005]","HB NWH TRICARE","151.05","95","","30.27","29.95","60.54","26","29.66","364.8","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.13","22.08","22.44","183","29.66","364.8","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","159.00","119.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","1 through 10","79.5","232","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","124.74","78.45","","111.33","73.24","111.33","1 through 10","79.5","232","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","175.39","99.79","175.39","340","35.02","364.8","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","132.13","73","","121.18","121.18","121.18","1 through 10","35.02","364.8","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","TRICARE [160005]","HB NWH TRICARE","171.95","95","","35.72","35.72","112.68","1 through 10","35.02","364.8","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","29.27","26.43","35.62","151","35.02","364.8","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.99","78.45","","77.33","58.00","77.33","1 through 10","90.5","240.73","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","14","51.33","364.8","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB NWH TRICARE","196.65","95","","52.37","52.37","52.37","1 through 10","51.33","364.8","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","51.33","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($52.38). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($34.76). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","52.24","51.84","52.24","1 through 10","51.33","364.8","fee schedule",""
"Ot Performance Test 15 Min","PX-43000044","CDM","97750","CPT","0431","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","36.78","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($37.53). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.49). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","36.78","31.44","36.87","1 through 10","36.78","364.8","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","172.62","71.69","172.62","72","38.35","364.8","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","TRICARE [160005]","HB NWH TRICARE","173.85","95","","82.92","39.39","148.66","13","38.35","364.8","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","32.31","29.62","38.35","70","38.35","364.8","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","104.31","1 through 10","91.5","254.62","percent of total billed charges",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB CH AETNA HMO / PPO","39.64","58.3","","28.28","28.28","28.51","1 through 10","15.19","364.8","percent of total billed charges",""
"Ot Wheelchair Management 15 Min","PX-43000036","CDM","97542","CPT","0431","RC","","","","both","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","33.59","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($34.28). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.37). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","24.87","24.87","24.87","1 through 10","33.59","364.8","fee schedule",""
"Other Aftercare And Convalescence,MODERATE","862","DRG","","","","","","","","inpatient","","","24317.30","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11299.1844","","Fee schedule rate ($15,191.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11299.1844","15191.96","15191.96","1 through 10","6814.07","25066.49","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","56631.47","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","18707.39","","Case rate ($20,154.25). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,584.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2763.63","2763.63","2763.63","1 through 10","2659","86997.54","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","36439.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22561.15","","Standard inlier is a Case rate ($22,561.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,792, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,202.64) for the length of stay and the standard reimbursement.","21535.94","21535.94","21535.94","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","36439.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24235.18","","Standard inlier is a Case rate ($24,235.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,792, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,440.08) for the length of stay and the standard reimbursement.","24235.18","24235.18","24235.18","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","36439.98","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","23299.51","","Fee schedule rate ($23,299.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23299.51","23299.51","23299.51","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","36439.98","","MASSHEALTH [3001]","HB NWH MEDICAID","9152.64","","Case rate ($9,860.52). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,290.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9885.88","9885.88","9885.88","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","36439.98","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9152.64","","Case rate ($9,860.52). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,290.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9885.88","9885.88","9885.88","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","14150.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12269.01","","Standard inlier is a Case rate ($12,269.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,366, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,741.53) for the length of stay and the standard reimbursement.","12269.01","12269.01","12269.01","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","14150.29","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10298.4861","","Fee schedule rate ($10,298.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10298.4861","10298.48","10298.48","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23571.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16155.39","","Standard inlier is a Case rate ($16,155.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,222, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,293.32) for the length of stay and the standard reimbursement.","16155.38","16155.38","16155.38","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23571.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17354.11","","Standard inlier is a Case rate ($17,354.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,222, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,463.34) for the length of stay and the standard reimbursement.","16565.28","16565.28","16565.28","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23571.58","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10298.4861","","Fee schedule rate ($22,240.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10298.4861","14158.12","14158.12","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23571.58","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22114.46","","Fee schedule rate ($22,114.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16755.61","16755.61","16755.61","1 through 10","4913.32","73026.21","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23571.58","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6465.79","","Case rate ($6,965.87). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,395.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6983.78","6983.78","6983.78","1 through 10","4913.32","73026.21","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","17316.14","12987.10","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6439.45","","Case rate ($6,251.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,422.39, add-ons for qualifying new technology services are included. If operating cost exceeds $51,564.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,419.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,774.13. The transfer operating threshold is the transfer adjustment factor * $6,422.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $477.76. The transfer capital threshold is the transfer adjustment factor * $477.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17104.99","17104.99","17104.99","1 through 10","6126.85","7407.22","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","17316.14","12987.10","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5831.34","5831.34","5831.34","1 through 10","6126.85","7407.22","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures With McC","831","MS-DRG","","","","","","","","inpatient","","","12711.83","9533.87","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5831.34","5831.34","5831.34","1 through 10","10210","12343.66","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures With McC","831","MS-DRG","","","","","","","","inpatient","","","12711.83","9533.87","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","10210.00","","Case rate ($10,418.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,702.50, add-ons for qualifying new technology services are included. If operating cost exceeds $55,844.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,738.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,622.21. The transfer operating threshold is the transfer adjustment factor * $10,702.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.16. The transfer capital threshold is the transfer adjustment factor * $796.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11131.56","11131.56","11131.56","1 through 10","10210","12343.66","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","12400.53","9300.40","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5831.34","5831.34","5831.34","1 through 10","4439.76","5140.3022","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,EXTREME","347","DRG","","","","","","","","inpatient","","","29243.21","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10204.8324","","Fee schedule rate ($61,217.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10204.8324","61217.26","61217.26","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","39399.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24264.95","","Standard inlier is a Case rate ($24,264.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,541, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,444.50) for the length of stay and the standard reimbursement.","24264.94","24264.94","24264.94","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","39399.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26065.39","","Standard inlier is a Case rate ($26,065.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,541, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,699.87) for the length of stay and the standard reimbursement.","26065.39","26065.39","26065.39","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","39399.13","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10204.8324","","Fee schedule rate ($23,208.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10204.8324","23208.08","23208.08","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","22374.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14218.70","","Standard inlier is a Case rate ($14,218.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,018.40) for the length of stay and the standard reimbursement.","14218.70","14218.70","14218.70","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","22374.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15273.72","","Standard inlier is a Case rate ($15,273.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,168.04) for the length of stay and the standard reimbursement.","15273.72","15273.72","15273.72","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","22374.26","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5019.56","","Case rate ($5,407.78). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,837.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5421.69","5421.69","5421.69","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","27573.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17930.27","","Standard inlier is a Case rate ($17,930.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,043, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,545.27) for the length of stay and the standard reimbursement.","17930.27","17930.27","17930.27","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","27573.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19260.69","","Standard inlier is a Case rate ($19,260.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,043, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,733.97) for the length of stay and the standard reimbursement.","19260.68","19260.68","19260.68","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","27573.26","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10715.0218","","Fee schedule rate ($14,943.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10715.0218","14944.00","14944.00","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","27573.26","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","6254.45","","Case rate ($6,738.19). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,168.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6755.51","6755.51","6755.51","1 through 10","5019.56","101007.55","case rate",""
"Other Bladder Procedures,MAJOR","445","DRG","","","","","","","","inpatient","","","54529.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","54092.35","","Standard inlier is a Case rate ($54,092.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $67,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,678.62) for the length of stay and the standard reimbursement.","40917.98","40917.98","40917.98","1 through 10","18571.455","74799.78","case rate",""
"Other Bladder Procedures,MAJOR","445","DRG","","","","","","","","inpatient","","","54529.11","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","23742.5349","","Fee schedule rate ($37,837.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23742.5349","37837.04","37837.04","1 through 10","18571.455","74799.78","case rate",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","23424.41","17568.31","MEDICARE [2001]","HB NWH MEDICARE","9773.89","","Case rate ($9,773.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,131.61, add-ons for qualifying new technology services are included. If operating cost exceeds $54,273.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,621.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,094.58. The transfer operating threshold is the transfer adjustment factor * $9,131.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.30. The transfer capital threshold is the transfer adjustment factor * $679.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9160.72","978.30","10076.68","1 through 10","8711.41","10422.0171","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","33652.38","25239.28","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14856.41","","Case rate ($14,423.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,817.06, add-ons for qualifying new technology services are included. If operating cost exceeds $59,959.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,044.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,321.46. The transfer operating threshold is the transfer adjustment factor * $14,817.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,102.24. The transfer capital threshold is the transfer adjustment factor * $1,102.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15570.37","15570.37","15570.37","1 through 10","14135.23","17089.17","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","33652.38","25239.28","MEDICARE [2001]","HB NWH MEDICARE","15859.22","","Case rate ($15,859.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,817.06, add-ons for qualifying new technology services are included. If operating cost exceeds $59,959.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,044.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,756.98. The transfer operating threshold is the transfer adjustment factor * $14,817.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,102.24. The transfer capital threshold is the transfer adjustment factor * $1,102.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16595.40","16595.40","16625.24","1 through 10","14135.23","17089.17","other","Inpatient DRG"
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","5393.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21177.80","","Standard inlier is a Case rate ($21,177.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,873, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,006.10) for the length of stay and the standard reimbursement.","12582.00","12582.00","12582.00","1 through 10","9057.82","27182.28","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","5393.05","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","10840.08","","Fee schedule rate ($10,840.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10523.98","10523.98","10523.98","1 through 10","9057.82","27182.28","case rate",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","25962.14","19471.60","MEDICARE [2001]","HB NWH MEDICARE","8345.95","","Case rate ($8,345.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,573.57, add-ons for qualifying new technology services are included. If operating cost exceeds $53,715.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,579.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,708.17. The transfer operating threshold is the transfer adjustment factor * $8,573.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $637.79. The transfer capital threshold is the transfer adjustment factor * $637.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9200.87","6802.75","9200.87","19","8179.03","9516.1847","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","37947.46","28460.59","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","19864.04","","Case rate ($19,864.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,558.71, add-ons for qualifying new technology services are included. If operating cost exceeds $63,700.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,322.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,483.45. The transfer operating threshold is the transfer adjustment factor * $18,558.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,380.59. The transfer capital threshold is the transfer adjustment factor * $1,380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18570.63","18570.63","18570.63","1 through 10","17704.7","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","37947.46","28460.59","MEDICARE [2001]","HB NWH MEDICARE","19864.04","","Case rate ($19,864.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,558.71, add-ons for qualifying new technology services are included. If operating cost exceeds $63,700.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,322.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,483.45. The transfer operating threshold is the transfer adjustment factor * $18,558.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,380.59. The transfer capital threshold is the transfer adjustment factor * $1,380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20553.37","8404.98","20590.32","24","17704.7","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","37947.46","28460.59","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","17704.70","","Case rate ($18,066.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,558.71, add-ons for qualifying new technology services are included. If operating cost exceeds $63,700.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,322.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,685.43. The transfer operating threshold is the transfer adjustment factor * $18,558.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,380.59. The transfer capital threshold is the transfer adjustment factor * $1,380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18361.84","18361.84","18391.27","1 through 10","17704.7","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","37947.46","28460.59","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","17704.70","","Case rate ($18,066.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,558.71, add-ons for qualifying new technology services are included. If operating cost exceeds $63,700.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,322.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,685.43. The transfer operating threshold is the transfer adjustment factor * $18,558.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,380.59. The transfer capital threshold is the transfer adjustment factor * $1,380.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16997.04","16997.04","16997.04","1 through 10","17704.7","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","54512.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","37353.51","","Standard inlier is a Case rate ($37,353.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,969, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,302.48) for the length of stay and the standard reimbursement.","37353.50","37353.50","37353.50","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","36864.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23679.53","","Standard inlier is a Case rate ($23,679.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,261, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,361.21) for the length of stay and the standard reimbursement.","23679.53","23679.53","23679.53","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","36864.88","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9792.4962","","Fee schedule rate ($23,004.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9792.4962","23004.84","23004.84","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","13961.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13588.34","","Standard inlier is a Case rate ($13,588.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,624, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,928.81) for the length of stay and the standard reimbursement.","12970.69","12970.69","12970.69","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","13961.13","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10282.0709","","Fee schedule rate ($10,282.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10282.0709","6855.04","6855.04","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","13961.13","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10771.65","","Fee schedule rate ($10,771.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10771.64","10771.64","10771.64","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17024.93","","Standard inlier is a Case rate ($17,024.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,416.62) for the length of stay and the standard reimbursement.","17024.93","17024.93","17024.93","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9792.4962","","Fee schedule rate ($9,792.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9792.4962","14361.42","14361.42","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10282.0709","","Fee schedule rate ($10,282.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10282.0709","15079.40","15079.40","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","MASSHEALTH [3001]","HB NWH MEDICAID","6675.99","","Case rate ($7,192.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,622.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7486.66","7486.66","7486.66","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","17682.20","","Fee schedule rate ($17,682.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17682.20","17682.20","17682.20","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","35114.90","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6675.99","","Case rate ($7,192.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,622.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9013.52","9013.52","9013.52","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","22219.11","16664.33","MEDICARE [2001]","HB NWH MEDICARE","28942.71","","Case rate ($28,942.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $29,732.02, add-ons for qualifying new technology services are included. If operating cost exceeds $74,874.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,153.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $26,730.94. The transfer operating threshold is the transfer adjustment factor * $29,732.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.77. The transfer capital threshold is the transfer adjustment factor * $2,211.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","728.09","728.09","728.09","1 through 10","28363.86","34291.26","other","Inpatient Replacement Plans DRG"
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","23030.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25243.77","","Standard inlier is a Case rate ($25,243.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,757, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,583.25) for the length of stay and the standard reimbursement.","25243.77","25243.77","25243.77","1 through 10","5235.46","38167.22","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","23030.37","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","25444.82","","Fee schedule rate ($25,444.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25444.82","25444.82","25444.82","1 through 10","5235.46","38167.22","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","16478.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16204.42","","Standard inlier is a Case rate ($16,204.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,300.28) for the length of stay and the standard reimbursement.","16204.41","16204.41","16204.41","1 through 10","5235.46","38167.22","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","16478.32","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9966.0783","","Fee schedule rate ($14,162.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9966.0783","14162.20","14162.20","1 through 10","5235.46","38167.22","case rate",""
"Other Digestive System And Abdominal Procedures,MINOR","229","DRG","","","","","","","","inpatient","","","39774.72","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","22359.5543","","Fee schedule rate ($22,359.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22359.5543","22359.56","22359.56","1 through 10","10490.35","52764.08","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","39560.49","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","21294.9174","","Fee schedule rate ($31,978.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21294.9174","30746.32","30746.32","1 through 10","10490.35","52764.08","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20634.72","15476.04","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8913.67","","Case rate ($8,913.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,327.92, add-ons for qualifying new technology services are included. If operating cost exceeds $53,470.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,561.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,294.15. The transfer operating threshold is the transfer adjustment factor * $8,327.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.52. The transfer capital threshold is the transfer adjustment factor * $619.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8117.27","8117.27","8119.71","1 through 10","7944.7","9308.5157","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20634.72","15476.04","MEDICARE [2001]","HB NWH MEDICARE","8913.67","","Case rate ($8,913.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,327.92, add-ons for qualifying new technology services are included. If operating cost exceeds $53,470.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,561.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,294.15. The transfer operating threshold is the transfer adjustment factor * $8,327.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.52. The transfer capital threshold is the transfer adjustment factor * $619.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9000.08","8983.81","9000.08","34","7944.7","9308.5157","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20634.72","15476.04","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7944.70","","Case rate ($8,106.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,327.92, add-ons for qualifying new technology services are included. If operating cost exceeds $53,470.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,561.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,487.32. The transfer operating threshold is the transfer adjustment factor * $8,327.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.52. The transfer capital threshold is the transfer adjustment factor * $619.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38.33","38.33","8026.00","1 through 10","7944.7","9308.5157","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20634.72","15476.04","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","7944.70","","Case rate ($8,106.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,327.92, add-ons for qualifying new technology services are included. If operating cost exceeds $53,470.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,561.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,487.32. The transfer operating threshold is the transfer adjustment factor * $8,327.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.52. The transfer capital threshold is the transfer adjustment factor * $619.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39.12","39.12","39.12","1 through 10","7944.7","9308.5157","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20634.72","15476.04","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7944.70","","Case rate ($8,106.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,327.92, add-ons for qualifying new technology services are included. If operating cost exceeds $53,470.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,561.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,487.32. The transfer operating threshold is the transfer adjustment factor * $8,327.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.52. The transfer capital threshold is the transfer adjustment factor * $619.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8023.58","8023.58","8023.58","1 through 10","7944.7","9308.5157","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","31525.62","23644.21","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13856.22","","Case rate ($13,856.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,234.10, add-ons for qualifying new technology services are included. If operating cost exceeds $59,376.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,000.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,797.34. The transfer operating threshold is the transfer adjustment factor * $14,234.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,058.88. The transfer capital threshold is the transfer adjustment factor * $1,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14284.74","14284.74","14284.74","1 through 10","13579.1","16416.81","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","31525.62","23644.21","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","13856.22","","Case rate ($13,856.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,234.10, add-ons for qualifying new technology services are included. If operating cost exceeds $59,376.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,000.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,797.34. The transfer operating threshold is the transfer adjustment factor * $14,234.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,058.88. The transfer capital threshold is the transfer adjustment factor * $1,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11309.29","11309.29","11309.29","1 through 10","13579.1","16416.81","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","31525.62","23644.21","HUMANA [1012]","HB NWH MEDICARE","13856.22","","Case rate ($13,856.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,234.10, add-ons for qualifying new technology services are included. If operating cost exceeds $59,376.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,000.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,797.34. The transfer operating threshold is the transfer adjustment factor * $14,234.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,058.88. The transfer capital threshold is the transfer adjustment factor * $1,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26492.91","26492.91","26492.91","1 through 10","13579.1","16416.81","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","31525.62","23644.21","MEDICARE [2001]","HB NWH MEDICARE","13856.22","","Case rate ($13,856.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,234.10, add-ons for qualifying new technology services are included. If operating cost exceeds $59,376.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,000.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,797.34. The transfer operating threshold is the transfer adjustment factor * $14,234.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,058.88. The transfer capital threshold is the transfer adjustment factor * $1,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15833.55","15804.93","15833.55","28","13579.1","16416.81","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","31525.62","23644.21","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13579.10","","Case rate ($13,856.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,234.10, add-ons for qualifying new technology services are included. If operating cost exceeds $59,376.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,000.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,797.34. The transfer operating threshold is the transfer adjustment factor * $14,234.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,058.88. The transfer capital threshold is the transfer adjustment factor * $1,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14130.62","14130.62","14130.89","1 through 10","13579.1","16416.81","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","17248.40","12936.30","MEDICARE [2001]","HB NWH MEDICARE","6182.52","","Case rate ($6,182.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,776.24, add-ons for qualifying new technology services are included. If operating cost exceeds $50,918.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,371.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,752.81. The transfer operating threshold is the transfer adjustment factor * $5,776.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.70. The transfer capital threshold is the transfer adjustment factor * $429.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6084.84","6073.92","6084.84","1 through 10","5510.44","6661.99","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","17248.40","12936.30","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","5510.44","","Case rate ($5,622.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,776.24, add-ons for qualifying new technology services are included. If operating cost exceeds $50,918.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,371.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,193.19. The transfer operating threshold is the transfer adjustment factor * $5,776.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $429.70. The transfer capital threshold is the transfer adjustment factor * $429.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5424.63","5424.63","5424.63","1 through 10","5510.44","6661.99","other","Inpatient DRG"
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","14360.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41246.49","","Fee schedule rate ($41,246.49). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,771.57) multiplied by length of stay and the outlier percent (100%).","5855.10","5855.10","5855.10","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23473.11","","Standard inlier is a Case rate ($23,473.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,730, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,332.10) for the length of stay and the standard reimbursement.","23473.11","23473.11","23473.11","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25214.81","","Standard inlier is a Case rate ($25,214.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,730, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,579.14) for the length of stay and the standard reimbursement.","25214.80","2917.50","25214.80","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($22,971.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","22971.62","22971.62","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9828.601","","Fee schedule rate ($24,120.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9828.601","24120.08","24120.08","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","11860.78","","Fee schedule rate ($11,860.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11861.07","11861.07","11861.07","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","23666.02","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29741.76","","Fee schedule rate ($29,741.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29741.76","29741.76","29741.76","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","16925.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11693.66","","Standard inlier is a Case rate ($11,693.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,659.96) for the length of stay and the standard reimbursement.","11693.65","11693.65","11693.65","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","16925.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12561.32","","Standard inlier is a Case rate ($12,561.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,783.03) for the length of stay and the standard reimbursement.","11990.34","11990.34","24068.67","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","16925.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($9,360.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","9360.62","9360.62","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","16925.95","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7647.23","","Fee schedule rate ($7,647.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7647.23","7647.23","7647.23","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","16925.95","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5274.30","","Case rate ($5,682.23). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,112.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4034.58","4034.58","4034.58","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16324.54","","Standard inlier is a Case rate ($16,324.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,317.33) for the length of stay and the standard reimbursement.","12466.18","12466.18","12466.18","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17535.81","","Standard inlier is a Case rate ($17,535.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,489.13) for the length of stay and the standard reimbursement.","17535.81","17535.81","17535.81","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($17,972.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","13597.60","13597.60","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9828.601","","Fee schedule rate ($18,871.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9828.601","14849.60","14849.60","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","19769.87","","Fee schedule rate ($19,769.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15556.66","15556.66","15556.66","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","MASSHEALTH [3001]","HB NWH MEDICAID","7034.69","","Case rate ($7,578.77). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,008.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6446.49","6446.49","6446.49","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","10396.86","","Fee schedule rate ($10,396.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10396.86","10396.86","10396.86","1 through 10","2404","44306.96","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","17335.10","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7034.69","","Case rate ($7,578.77). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,008.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3305.05","1139.14","6457.05","1 through 10","2404","44306.96","case rate",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","40677.56","30508.17","MEDICARE [2001]","HB NWH MEDICARE","20147.95","","Case rate ($20,147.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,697.42, add-ons for qualifying new technology services are included. If operating cost exceeds $65,839.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,481.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,608.27. The transfer operating threshold is the transfer adjustment factor * $20,697.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.69. The transfer capital threshold is the transfer adjustment factor * $1,539.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21532.11","21532.11","21532.11","1 through 10","19744.99","22270.028","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","40677.56","30508.17","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","19744.99","","Case rate ($20,147.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,697.42, add-ons for qualifying new technology services are included. If operating cost exceeds $65,839.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,481.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,608.27. The transfer operating threshold is the transfer adjustment factor * $20,697.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.69. The transfer capital threshold is the transfer adjustment factor * $1,539.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19228.52","19228.52","19228.52","1 through 10","19744.99","22270.028","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","40677.56","30508.17","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","19744.99","","Case rate ($20,147.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,697.42, add-ons for qualifying new technology services are included. If operating cost exceeds $65,839.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,481.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,608.27. The transfer operating threshold is the transfer adjustment factor * $20,697.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.69. The transfer capital threshold is the transfer adjustment factor * $1,539.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19195.88","19195.88","19195.88","1 through 10","19744.99","22270.028","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","53656.83","40242.62","MEDICARE [2001]","HB NWH MEDICARE","38058.89","","Case rate ($38,058.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $39,096.82, add-ons for qualifying new technology services are included. If operating cost exceeds $84,239.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,850.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $35,150.47. The transfer operating threshold is the transfer adjustment factor * $39,096.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.42. The transfer capital threshold is the transfer adjustment factor * $2,908.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40712.55","40712.02","40785.74","1 through 10","37297.71","42183.5073","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","53656.83","40242.62","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","37297.71","","Case rate ($38,058.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $39,096.82, add-ons for qualifying new technology services are included. If operating cost exceeds $84,239.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,850.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $35,150.47. The transfer operating threshold is the transfer adjustment factor * $39,096.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,908.42. The transfer capital threshold is the transfer adjustment factor * $2,908.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18895.02","18895.02","18895.02","1 through 10","37297.71","42183.5073","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","26811.38","20108.53","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9745.31","","Case rate ($9,745.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,104.91, add-ons for qualifying new technology services are included. If operating cost exceeds $54,247.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,067.99. The transfer operating threshold is the transfer adjustment factor * $9,104.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.32. The transfer capital threshold is the transfer adjustment factor * $677.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9208.32","9208.32","9208.32","1 through 10","8685.94","10501.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","26811.38","20108.53","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","24907.37","24907.37","24907.37","1 through 10","8685.94","10501.1","case rate",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","26811.38","20108.53","MEDICARE [2001]","HB NWH MEDICARE","9745.31","","Case rate ($9,745.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,104.91, add-ons for qualifying new technology services are included. If operating cost exceeds $54,247.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,067.99. The transfer operating threshold is the transfer adjustment factor * $9,104.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.32. The transfer capital threshold is the transfer adjustment factor * $677.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10104.41","1158.33","10122.58","24","8685.94","10501.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","26811.38","20108.53","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8685.94","","Case rate ($8,863.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,104.91, add-ons for qualifying new technology services are included. If operating cost exceeds $54,247.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,185.88. The transfer operating threshold is the transfer adjustment factor * $9,104.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.32. The transfer capital threshold is the transfer adjustment factor * $677.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9035.16","9035.16","9035.16","1 through 10","8685.94","10501.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","26811.38","20108.53","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8685.94","","Case rate ($8,863.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,104.91, add-ons for qualifying new technology services are included. If operating cost exceeds $54,247.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,185.88. The transfer operating threshold is the transfer adjustment factor * $9,104.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.32. The transfer capital threshold is the transfer adjustment factor * $677.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9028.29","9028.29","9028.29","1 through 10","8685.94","10501.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15672.05","","Case rate ($15,215.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,052.83. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16320.13","16320.13","16320.13","1 through 10","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","16729.91","","Case rate ($16,729.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,567.16. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15724.44","15724.44","17150.47","1 through 10","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","MEDICARE [2001]","HB NWH MEDICARE","16729.91","","Case rate ($16,729.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,567.16. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17398.07","11599.13","17429.35","21","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14911.27","","Case rate ($15,215.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,052.83. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13816.15","13816.15","15548.98","1 through 10","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","14911.27","","Case rate ($15,215.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,052.83. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18336.91","18336.91","18336.91","1 through 10","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","46759.43","35069.57","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14911.27","","Case rate ($15,215.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,630.54, add-ons for qualifying new technology services are included. If operating cost exceeds $60,772.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,104.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,052.83. The transfer operating threshold is the transfer adjustment factor * $15,630.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.76. The transfer capital threshold is the transfer adjustment factor * $1,162.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15542.98","15542.98","17408.34","1 through 10","14911.27","18027.39","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","17617.71","13213.28","MEDICARE [2001]","HB NWH MEDICARE","7585.71","","Case rate ($7,585.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,087.23, add-ons for qualifying new technology services are included. If operating cost exceeds $52,229.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,469.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $7,058.49. The transfer operating threshold is the transfer adjustment factor * $7,087.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.22. The transfer capital threshold is the transfer adjustment factor * $527.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7546.75","7546.75","7546.75","1 through 10","6761.1","7658.0416","other","Inpatient DRG"
"Other Disorders Of Nervous System,EXTREME","058","DRG","","","","","","","","inpatient","","","92456.36","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","52307.33","","Fee schedule rate ($52,307.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52307.33","52307.33","52307.33","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","35058.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32524.05","","Fee schedule rate ($32,524.05). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,762.52) multiplied by length of stay and the outlier percent (100%).","7185.40","7185.40","7185.40","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","35058.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34937.32","","Fee schedule rate ($34,937.32). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,042.45) multiplied by length of stay and the outlier percent (100%).","7716.08","7716.08","7716.08","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","35058.69","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","14110.50","","Case rate ($15,201.84). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,631.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15240.94","15240.94","15240.94","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","39487.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18501.47","","Standard inlier is a Case rate ($18,501.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,627, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,626.36) for the length of stay and the standard reimbursement.","17660.73","17660.73","17660.73","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","39487.21","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7999.23","","Fee schedule rate ($7,999.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7999.23","7999.23","7999.23","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","39487.21","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6047.69","","Case rate ($6,515.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,945.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6532.18","6532.18","6532.18","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","28409.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24826.34","","Standard inlier is a Case rate ($24,826.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,524.20) for the length of stay and the standard reimbursement.","23701.48","23701.48","23701.48","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","28409.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26668.44","","Standard inlier is a Case rate ($26,668.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,785.47) for the length of stay and the standard reimbursement.","25456.23","25456.23","25458.97","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","28409.75","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9598.45","","Fee schedule rate ($9,598.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9598.45","9598.45","9598.45","1 through 10","6047.69","100427.16","case rate",""
"Other Disorders Of The Eye With McC Or Thrombolytic Agent","124","MS-DRG","","","","","","","","inpatient","","","73066.54","54799.90","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11233.98","","Case rate ($11,463.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,775.86, add-ons for qualifying new technology services are included. If operating cost exceeds $56,918.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,817.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,587.23. The transfer operating threshold is the transfer adjustment factor * $11,775.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $876.01. The transfer capital threshold is the transfer adjustment factor * $876.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11141.85","11141.85","11141.85","1 through 10","11233.98","12894.2671","other","Inpatient DRG"
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","21702.68","16277.01","MEDICARE [2001]","HB NWH MEDICARE","7314.23","","Case rate ($7,314.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,833.58, add-ons for qualifying new technology services are included. If operating cost exceeds $51,975.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,450.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,805.87. The transfer operating threshold is the transfer adjustment factor * $6,833.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.35. The transfer capital threshold is the transfer adjustment factor * $508.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7880.52","7880.52","7880.52","1 through 10","6519.13","7881.47","other","Inpatient DRG"
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","47974.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44675.63","","Fee schedule rate ($44,675.63). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,169.24) multiplied by length of stay and the outlier percent (100%).","6341.51","6341.51","6341.51","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","47974.56","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6248.00","","Per diem ($6,248). If length of stay < 8.26, first 1 days paid at a per diem of $12,496 instead.","51611.55","51611.55","51611.55","1 through 10","2492","97541.32","per diem","Estimated amount calculated based on 2 day length of stay."
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","28283.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22181.17","","Standard inlier is a Case rate ($22,181.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,148.70) for the length of stay and the standard reimbursement.","22181.17","22181.17","22181.17","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","28283.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23827.00","","Standard inlier is a Case rate ($23,827.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,382.14) for the length of stay and the standard reimbursement.","23827.00","23827.00","23827.00","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","28283.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10664.0694","","Fee schedule rate ($59,116.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10664.0694","23765.02","23765.02","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","28283.76","","MASSHEALTH [3001]","HB NWH MEDICAID","10157.92","","Case rate ($10,943.55). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,373.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10971.70","10971.70","10971.70","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MINOR","283","DRG","","","","","","","","inpatient","","","20629.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12795.69","","Standard inlier is a Case rate ($12,795.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,867, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,816.29) for the length of stay and the standard reimbursement.","12795.69","12795.69","12795.69","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MINOR","283","DRG","","","","","","","","inpatient","","","20629.02","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","13701.53","","Fee schedule rate ($13,701.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16454.58","16454.58","16454.58","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","28136.52","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16374.48","","Standard inlier is a Case rate ($16,374.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,286, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,324.29) for the length of stay and the standard reimbursement.","16374.48","16374.48","16374.48","1 through 10","2492","97541.32","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","28136.52","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","11197.2183","","Fee schedule rate ($15,342.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11197.2183","15342.04","15342.04","1 through 10","2492","97541.32","case rate",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","","","","inpatient","","","24441.40","18331.05","MEDICARE [2001]","HB NWH MEDICARE","8730.77","","Case rate ($8,730.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,157.04, add-ons for qualifying new technology services are included. If operating cost exceeds $53,299.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,548.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,123.96. The transfer operating threshold is the transfer adjustment factor * $8,157.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.80. The transfer capital threshold is the transfer adjustment factor * $606.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8910.31","1090.50","8926.45","1 through 10","7781.68","9232.3704","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","28639.95","21479.96","MEDICARE [2001]","HB NWH MEDICARE","13546.05","","Case rate ($13,546.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,915.47, add-ons for qualifying new technology services are included. If operating cost exceeds $59,057.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,977.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,510.87. The transfer operating threshold is the transfer adjustment factor * $13,915.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,035.18. The transfer capital threshold is the transfer adjustment factor * $1,035.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1305.65","1305.65","1305.65","1 through 10","13275.13","16049.33","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/McC","156","MS-DRG","","","","","","","","inpatient","","","16268.86","12201.64","MEDICARE [2001]","HB NWH MEDICARE","5987.63","","Case rate ($5,987.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,150.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,399.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,530.07. The transfer operating threshold is the transfer adjustment factor * $6,150.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.57. The transfer capital threshold is the transfer adjustment factor * $457.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6417.50","6417.50","6417.50","1 through 10","5867.88","6649.3636","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/McC","156","MS-DRG","","","","","","","","inpatient","","","16268.86","12201.64","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","5867.88","","Case rate ($5,987.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,150.93, add-ons for qualifying new technology services are included. If operating cost exceeds $51,293.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,399.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,530.07. The transfer operating threshold is the transfer adjustment factor * $6,150.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $457.57. The transfer capital threshold is the transfer adjustment factor * $457.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5765.01","5765.01","5765.01","1 through 10","5867.88","6649.3636","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","","","","inpatient","","","32773.22","24579.91","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15464.13","","Case rate ($15,013.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,423.17, add-ons for qualifying new technology services are included. If operating cost exceeds $60,565.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,089.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,866.38. The transfer operating threshold is the transfer adjustment factor * $15,423.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,147.33. The transfer capital threshold is the transfer adjustment factor * $1,147.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15757.15","15757.15","15757.15","1 through 10","14713.45","17372.0063","other","Inpatient DRG"
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","43928.59","","MASSHEALTH [3001]","HB NWH MEDICAID","10953.01","","Case rate ($11,800.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,230.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11800.97","11800.97","11800.97","1 through 10","4760.24","32318.16","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","15893.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10828.28","","Standard inlier is a Case rate ($10,828.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,537.12) for the length of stay and the standard reimbursement.","10828.27","10828.27","10828.27","1 through 10","4760.24","32318.16","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","15893.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11631.73","","Standard inlier is a Case rate ($11,631.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,651.07) for the length of stay and the standard reimbursement.","11103.01","11103.01","11103.01","1 through 10","4760.24","32318.16","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","15893.66","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12450.46","","Fee schedule rate ($12,450.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12450.46","12450.46","12450.46","1 through 10","4760.24","32318.16","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","15099.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16074.27","","Standard inlier is a Case rate ($16,074.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,281.68) for the length of stay and the standard reimbursement.","16074.27","16074.27","16074.27","1 through 10","4760.24","32318.16","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","36949.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21421.21","","Standard inlier is a Case rate ($21,421.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,040.82) for the length of stay and the standard reimbursement.","23853.09","23853.09","23853.09","1 through 10","2205","42162.25","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","36949.34","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9514.9998","","Fee schedule rate ($25,553.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9514.9998","25553.12","25553.12","1 through 10","2205","42162.25","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","36949.34","","MASSHEALTH [3001]","HB NWH MEDICAID","9439.37","","Case rate ($10,169.43). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,599.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13805.93","13805.93","13805.93","1 through 10","2205","42162.25","case rate",""
"Other Endocrine Disorders,MINOR","424","DRG","","","","","","","","inpatient","","","22832.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12521.82","","Standard inlier is a Case rate ($12,521.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,777.42) for the length of stay and the standard reimbursement.","11952.64","11952.64","11952.64","1 through 10","2205","42162.25","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","41887.07","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7214.04","","Case rate ($7,771.99). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,201.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,539.01 and the sum of the standard inlier and any outlier amount.","9739.97","9739.97","9739.97","1 through 10","2205","42162.25","case rate",""
"Other Esophageal Disorders,EXTREME","243","DRG","","","","","","","","inpatient","","","58063.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45096.98","","Standard inlier is a Case rate ($45,096.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,717, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,401.33) for the length of stay and the standard reimbursement.","45096.97","45096.97","45096.97","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","24971.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23306.41","","Standard inlier is a Case rate ($23,306.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,558, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,308.44) for the length of stay and the standard reimbursement.","22247.33","22247.33","22247.33","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MINOR","243","DRG","","","","","","","","inpatient","","","33714.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12434.01","","Standard inlier is a Case rate ($12,434.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,403, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,765.06) for the length of stay and the standard reimbursement.","12434.00","12434.00","12434.00","1 through 10","4898.47","85801.28","case rate",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","10034.93","7526.20","MEDICARE [2001]","HB NWH MEDICARE","4817.14","","Case rate ($4,817.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,948.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,090.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,310.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,449.02. The transfer operating threshold is the transfer adjustment factor * $4,948.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.12. The transfer capital threshold is the transfer adjustment factor * $368.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5411.47","266.67","5421.28","1 through 10","4720.8","5607.063","other","Inpatient Replacement Plans DRG"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","10034.93","7526.20","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4720.80","","Case rate ($4,817.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $4,948.52, add-ons for qualifying new technology services are included. If operating cost exceeds $50,090.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,310.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,449.02. The transfer operating threshold is the transfer adjustment factor * $4,948.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $368.12. The transfer capital threshold is the transfer adjustment factor * $368.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4833.07","4833.07","4833.07","1 through 10","4720.8","5607.063","other","Inpatient DRG"
"Other Female Reproductive System And Related Procedures,MINOR","518","DRG","","","","","","","","inpatient","","","48306.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20953.96","","Standard inlier is a Case rate ($20,953.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,660, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,974.33) for the length of stay and the standard reimbursement.","20953.96","20953.96","20953.96","1 through 10","8197.62","33585.35","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","45586.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","37918.33","","Standard inlier is a Case rate ($37,918.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $47,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,382.35) for the length of stay and the standard reimbursement.","37918.32","37918.32","37918.32","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","45586.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($41,206.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","41206.26","41206.26","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","45586.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($41,206.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","41206.26","41206.26","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","45586.69","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","41790.33","","Fee schedule rate ($41,790.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41790.33","41790.33","41790.33","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19178.08","","Standard inlier is a Case rate ($19,178.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,722.40) for the length of stay and the standard reimbursement.","18306.60","18306.60","19306.60","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20601.09","","Standard inlier is a Case rate ($20,601.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,924.24) for the length of stay and the standard reimbursement.","20601.08","20601.08","20601.08","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($22,971.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","15707.86","15707.86","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($22,971.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","15707.86","15707.86","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","MASSHEALTH [3001]","HB NWH MEDICAID","8645.43","","Case rate ($9,314.08). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,744.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11672.54","11672.54","11672.54","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","22387.38","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","18909.85","","Fee schedule rate ($18,909.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18909.85","18909.85","18909.85","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","13451.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10607.64","","Standard inlier is a Case rate ($10,607.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,530, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,505.80) for the length of stay and the standard reimbursement.","10125.69","10125.61","10607.64","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","13451.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11394.72","","Standard inlier is a Case rate ($11,394.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,530, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,617.43) for the length of stay and the standard reimbursement.","11394.72","11394.72","11394.72","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","13451.66","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($7,672.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","7672.18","7672.18","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","13451.66","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($7,672.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","7672.18","7672.18","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","13451.66","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3991.43","","Case rate ($4,300.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,730.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4311.19","4311.19","4311.19","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13260.16","","Standard inlier is a Case rate ($13,260.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,882.33) for the length of stay and the standard reimbursement.","13260.16","12657.60","13260.16","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14244.06","","Standard inlier is a Case rate ($14,244.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,021.88) for the length of stay and the standard reimbursement.","13596.60","13596.60","14244.06","14","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($8,576.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","10089.54","10089.54","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($8,576.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","10089.54","10089.54","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8055.7594","","Fee schedule rate ($9,004.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8055.7594","10593.96","10593.96","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9828.601","","Fee schedule rate ($9,004.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9828.601","10593.96","10593.96","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5618.81","","Fee schedule rate ($5,618.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6417.82","6417.82","6417.82","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11975.98","","Fee schedule rate ($11,975.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.31","5689.59","14089.56","1 through 10","3991.43","67989.7","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","17178.71","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5221.75","","Case rate ($5,625.62). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,055.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7050.10","7050.10","7050.10","1 through 10","3991.43","67989.7","case rate",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With McC","423","MS-DRG","","","","","","","","inpatient","","","73886.77","55415.08","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","37060.74","","Case rate ($35,981.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $36,962.56, add-ons for qualifying new technology services are included. If operating cost exceeds $82,104.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,691.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $33,231.63. The transfer operating threshold is the transfer adjustment factor * $36,962.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,749.65. The transfer capital threshold is the transfer adjustment factor * $2,749.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","36403.21","36403.21","36403.21","1 through 10","35261.67","40222.5186","other","Inpatient DRG"
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MAJOR","264","DRG","","","","","","","","inpatient","","","49836.98","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","21268.57","","Case rate ($22,913.53). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $65,343.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22972.45","22972.45","22972.45","1 through 10","19266.42","259425.55","case rate",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","20525.25","15393.94","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9201.38","","Case rate ($8,933.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,177, add-ons for qualifying new technology services are included. If operating cost exceeds $54,319.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,250.69. The transfer operating threshold is the transfer adjustment factor * $9,177.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.68. The transfer capital threshold is the transfer adjustment factor * $682.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9430.33","9430.33","9430.33","1 through 10","8754.71","10384.4389","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","20525.25","15393.94","MEDICARE [2001]","HB NWH MEDICARE","8933.38","","Case rate ($8,933.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,177, add-ons for qualifying new technology services are included. If operating cost exceeds $54,319.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,250.69. The transfer operating threshold is the transfer adjustment factor * $9,177.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.68. The transfer capital threshold is the transfer adjustment factor * $682.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10040.34","10022.20","10040.34","1 through 10","8754.71","10384.4389","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","20525.25","15393.94","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","8754.71","","Case rate ($8,933.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,177, add-ons for qualifying new technology services are included. If operating cost exceeds $54,319.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,250.69. The transfer operating threshold is the transfer adjustment factor * $9,177.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.68. The transfer capital threshold is the transfer adjustment factor * $682.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10191.60","10191.60","10191.60","1 through 10","8754.71","10384.4389","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","20525.25","15393.94","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8754.71","","Case rate ($8,933.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,177, add-ons for qualifying new technology services are included. If operating cost exceeds $54,319.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,624.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,250.69. The transfer operating threshold is the transfer adjustment factor * $9,177.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.68. The transfer capital threshold is the transfer adjustment factor * $682.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8953.68","8953.68","8953.68","1 through 10","8754.71","10384.4389","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","28421.86","21316.39","MEDICARE [2001]","HB NWH MEDICARE","19940.24","","Case rate ($19,940.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,629.91, add-ons for qualifying new technology services are included. If operating cost exceeds $63,772.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,327.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,554.36. The transfer operating threshold is the transfer adjustment factor * $18,629.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,385.88. The transfer capital threshold is the transfer adjustment factor * $1,385.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20465.57","15186.10","20502.37","1 through 10","17772.61","21204.9827","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC","869","MS-DRG","","","","","","","","inpatient","","","18802.02","14101.51","MEDICARE [2001]","HB NWH MEDICARE","6951.27","","Case rate ($6,951.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,494.48, add-ons for qualifying new technology services are included. If operating cost exceeds $51,636.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,425.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,468.14. The transfer operating threshold is the transfer adjustment factor * $6,494.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.13. The transfer capital threshold is the transfer adjustment factor * $483.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6880.32","6880.32","6880.32","1 through 10","6195.63","7116.1244","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases,EXTREME","724","DRG","","","","","","","","inpatient","","","54059.31","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","19311.70","","Case rate ($20,805.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,235.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20858.81","20858.81","20858.81","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","15273.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14333.60","","Standard inlier is a Case rate ($14,333.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,034.59) for the length of stay and the standard reimbursement.","13682.06","13682.06","14333.59","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","15273.96","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12647.5824","","Fee schedule rate ($12,647.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12647.5824","12647.58","12647.58","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","15273.96","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","15350.66","","Fee schedule rate ($15,350.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15350.66","15350.66","15350.66","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","24639.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15986.23","","Standard inlier is a Case rate ($15,986.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,048, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,269.31) for the length of stay and the standard reimbursement.","75403.62","75403.62","75403.62","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","24639.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17172.40","","Standard inlier is a Case rate ($17,172.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,048, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,437.55) for the length of stay and the standard reimbursement.","17172.40","17172.40","17172.40","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","24639.62","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13279.8968","","Fee schedule rate ($16,474.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13279.8968","16474.72","16474.72","1 through 10","6121.73","57729.39","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","24639.62","","MASSHEALTH [3001]","HB NWH MEDICAID","6570.89","","Case rate ($7,079.10). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,509.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1667.14","1494.00","10661.99","1 through 10","6121.73","57729.39","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","58696.71","44022.53","MEDICARE [2001]","HB NWH MEDICARE","15156.67","","Case rate ($15,156.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,570.02, add-ons for qualifying new technology services are included. If operating cost exceeds $60,712.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,100.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,998.41. The transfer operating threshold is the transfer adjustment factor * $15,570.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.26. The transfer capital threshold is the transfer adjustment factor * $1,158.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16152.91","16152.91","16152.91","1 through 10","14853.54","16706.4766","other","Inpatient Replacement Plans DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","58696.71","44022.53","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14853.54","","Case rate ($15,156.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,570.02, add-ons for qualifying new technology services are included. If operating cost exceeds $60,712.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,100.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,998.41. The transfer operating threshold is the transfer adjustment factor * $15,570.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.26. The transfer capital threshold is the transfer adjustment factor * $1,158.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14410.19","14410.19","14410.19","1 through 10","14853.54","16706.4766","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC","923","MS-DRG","","","","","","","","inpatient","","","11963.95","8972.96","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9081.81","","Case rate ($8,817.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,057.74, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,615.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,143.47. The transfer operating threshold is the transfer adjustment factor * $9,057.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.81. The transfer capital threshold is the transfer adjustment factor * $673.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9180.50","9180.50","9180.50","1 through 10","8640.94","10085.7911","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC","923","MS-DRG","","","","","","","","inpatient","","","11963.95","8972.96","MEDICARE [2001]","HB NWH MEDICARE","9694.83","","Case rate ($9,694.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,057.74, add-ons for qualifying new technology services are included. If operating cost exceeds $54,200.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,615.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,021.01. The transfer operating threshold is the transfer adjustment factor * $9,057.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $673.81. The transfer capital threshold is the transfer adjustment factor * $673.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9751.61","9751.61","9751.61","1 through 10","8640.94","10085.7911","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses,MAJOR","815","DRG","","","","","","","","inpatient","","","58696.71","","MASSHEALTH [3001]","HB NWH MEDICAID","10999.84","","Case rate ($11,850.59). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,280.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11881.07","11881.07","11881.07","1 through 10","4184.49","71732.32","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses,MINOR","815","DRG","","","","","","","","inpatient","","","10092.00","","MASSHEALTH [3001]","HB NWH MEDICAID","4184.49","","Case rate ($4,508.12). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,938.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5649.65","5649.65","5649.65","1 through 10","4184.49","71732.32","case rate",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","22046.77","16535.08","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9057.71","","Case rate ($8,793.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,033.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,175.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,121.87. The transfer operating threshold is the transfer adjustment factor * $9,033.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.02. The transfer capital threshold is the transfer adjustment factor * $672.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9159.83","9159.83","9159.83","1 through 10","8618.01","10085.7911","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","22046.77","16535.08","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9669.10","","Case rate ($9,669.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,033.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,175.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,997.08. The transfer operating threshold is the transfer adjustment factor * $9,033.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.02. The transfer capital threshold is the transfer adjustment factor * $672.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8873.67","8873.67","8873.67","1 through 10","8618.01","10085.7911","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","22046.77","16535.08","FALLON HEALTH [1008]","HB NWH MEDICARE","9669.10","","Case rate ($9,669.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,033.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,175.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,997.08. The transfer operating threshold is the transfer adjustment factor * $9,033.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.02. The transfer capital threshold is the transfer adjustment factor * $672.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8873.67","8873.67","8873.67","1 through 10","8618.01","10085.7911","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","22046.77","16535.08","MEDICARE [2001]","HB NWH MEDICARE","9669.10","","Case rate ($9,669.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,033.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,175.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,997.08. The transfer operating threshold is the transfer adjustment factor * $9,033.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.02. The transfer capital threshold is the transfer adjustment factor * $672.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9734.10","6094.75","9751.61","48","8618.01","10085.7911","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","22046.77","16535.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8618.01","","Case rate ($8,793.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,033.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,175.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,121.87. The transfer operating threshold is the transfer adjustment factor * $9,033.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.02. The transfer capital threshold is the transfer adjustment factor * $672.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5435.12","5435.12","5435.12","1 through 10","8618.01","10085.7911","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14763.61","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15048.83","15044.26","15091.66","1 through 10","14046.93","16622.4201","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14333.60","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14495.19","14495.19","14495.19","1 through 10","14046.93","16622.4201","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","FALLON HEALTH [1008]","HB NWH MEDICARE","14333.60","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14620.07","14620.07","14620.07","1 through 10","14046.93","16622.4201","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","MEDICARE [2001]","HB NWH MEDICARE","14333.60","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16042.80","10026.75","16071.64","97","14046.93","16622.4201","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","MOLINA [1014]","HB NWH MEDICARE","14333.60","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28948.15","28948.15","28990.45","1 through 10","14046.93","16622.4201","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14046.93","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14338.21","14327.67","14350.98","1 through 10","14046.93","16622.4201","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","29537.25","22152.94","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14046.93","","Case rate ($14,333.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,724.50, add-ons for qualifying new technology services are included. If operating cost exceeds $59,866.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,238.24. The transfer operating threshold is the transfer adjustment factor * $14,724.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,095.36. The transfer capital threshold is the transfer adjustment factor * $1,095.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14327.88","8973.44","56004.16","1 through 10","14046.93","16622.4201","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses Without Cc/McC","700","MS-DRG","","","","","","","","inpatient","","","26097.91","19573.43","MEDICARE [2001]","HB NWH MEDICARE","6572.13","","Case rate ($6,572.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,140.25, add-ons for qualifying new technology services are included. If operating cost exceeds $51,282.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,398.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,115.35. The transfer operating threshold is the transfer adjustment factor * $6,140.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $456.77. The transfer capital threshold is the transfer adjustment factor * $456.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6625.48","6625.48","6625.48","1 through 10","5857.71","6864.9438","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,EXTREME","468","DRG","","","","","","","","inpatient","","","49020.57","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16109.00","","Per diem ($16,109). If length of stay < 4, first 1 days paid at a per diem of $32,218 instead.","48326.88","48326.88","48326.88","1 through 10","2380","40570.16","per diem","Estimated amount calculated based on 2 day length of stay."
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","23440.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21546.23","","Standard inlier is a Case rate ($21,546.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,752, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,058.57) for the length of stay and the standard reimbursement.","21546.23","21546.23","21546.23","1 through 10","2380","40570.16","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MINOR","468","DRG","","","","","","","","inpatient","","","16308.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11787.10","","Standard inlier is a Case rate ($11,787.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,673.13) for the length of stay and the standard reimbursement.","11251.32","11251.32","11251.32","1 through 10","2380","40570.16","case rate",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","54771.98","41078.98","MEDICARE [2001]","HB NWH MEDICARE","22277.97","","Case rate ($22,277.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,814.02, add-ons for qualifying new technology services are included. If operating cost exceeds $65,956.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,490.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,729.62. The transfer operating threshold is the transfer adjustment factor * $20,814.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.36. The transfer capital threshold is the transfer adjustment factor * $1,548.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22071.38","22071.38","22071.38","1 through 10","19856.22","22827.7676","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","85276.15","63957.11","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","40025.30","","Case rate ($40,025.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,395.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,537.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,723.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $37,243.46. The transfer operating threshold is the transfer adjustment factor * $37,395.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,781.83. The transfer capital threshold is the transfer adjustment factor * $2,781.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36128.87","36128.87","36128.87","1 through 10","35674.31","41430.9544","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","85276.15","63957.11","MEDICARE [2001]","HB NWH MEDICARE","40025.30","","Case rate ($40,025.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,395.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,537.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,723.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $37,243.46. The transfer operating threshold is the transfer adjustment factor * $37,395.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,781.83. The transfer capital threshold is the transfer adjustment factor * $2,781.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39986.26","39986.26","40058.15","1 through 10","35674.31","41430.9544","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","85276.15","63957.11","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","35674.31","","Case rate ($36,402.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,395.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,537.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,723.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $33,620.52. The transfer operating threshold is the transfer adjustment factor * $37,395.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,781.83. The transfer capital threshold is the transfer adjustment factor * $2,781.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35715.84","35715.84","35715.84","1 through 10","35674.31","41430.9544","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","85276.15","63957.11","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","35674.31","","Case rate ($36,402.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,395.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,537.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,723.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $33,620.52. The transfer operating threshold is the transfer adjustment factor * $37,395.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,781.83. The transfer capital threshold is the transfer adjustment factor * $2,781.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35722.67","35722.67","35722.67","1 through 10","35674.31","41430.9544","other","Inpatient DRG"
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,EXTREME","447","DRG","","","","","","","","inpatient","","","138152.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","102911.52","","Standard inlier is a Case rate ($102,911.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $117,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,608.69) for the length of stay and the standard reimbursement.","50481.28","50481.28","50481.28","1 through 10","16042.68","184635.59","case rate",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","112278.34","84208.75","MEDICARE [2001]","HB NWH MEDICARE","33878.03","","Case rate ($33,878.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,651.79, add-ons for qualifying new technology services are included. If operating cost exceeds $76,794.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,296.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $31,523.45. The transfer operating threshold is the transfer adjustment factor * $31,651.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,354.58. The transfer capital threshold is the transfer adjustment factor * $2,354.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","32873.94","32873.94","32933.04","1 through 10","30195.29","36505.42","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","112278.34","84208.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","30195.29","","Case rate ($30,811.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,651.79, add-ons for qualifying new technology services are included. If operating cost exceeds $76,794.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,296.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $28,456.94. The transfer operating threshold is the transfer adjustment factor * $31,651.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,354.58. The transfer capital threshold is the transfer adjustment factor * $2,354.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","29373.82","29373.82","29373.82","1 through 10","30195.29","36505.42","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","103158.64","77368.98","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","47084.87","","Case rate ($45,713.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,960.15, add-ons for qualifying new technology services are included. If operating cost exceeds $92,102.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,435.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,220.10. The transfer operating threshold is the transfer adjustment factor * $46,960.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,493.38. The transfer capital threshold is the transfer adjustment factor * $3,493.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","45940.98","45940.98","45940.98","1 through 10","44799.2","50760.237","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","103158.64","77368.98","MEDICARE [2001]","HB NWH MEDICARE","45713.47","","Case rate ($45,713.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,960.15, add-ons for qualifying new technology services are included. If operating cost exceeds $92,102.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,435.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,220.10. The transfer operating threshold is the transfer adjustment factor * $46,960.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,493.38. The transfer capital threshold is the transfer adjustment factor * $3,493.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","104775.44","104775.44","104775.44","1 through 10","44799.2","50760.237","other","Inpatient Replacement Plans DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","103158.64","77368.98","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","44799.20","","Case rate ($45,713.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,960.15, add-ons for qualifying new technology services are included. If operating cost exceeds $92,102.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,435.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,220.10. The transfer operating threshold is the transfer adjustment factor * $46,960.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,493.38. The transfer capital threshold is the transfer adjustment factor * $3,493.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","43774.67","43774.67","43774.67","1 through 10","44799.2","50760.237","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","103158.64","77368.98","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","44799.20","","Case rate ($45,713.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,960.15, add-ons for qualifying new technology services are included. If operating cost exceeds $92,102.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,435.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,220.10. The transfer operating threshold is the transfer adjustment factor * $46,960.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,493.38. The transfer capital threshold is the transfer adjustment factor * $3,493.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","43768.11","43768.11","43768.11","1 through 10","44799.2","50760.237","other","Inpatient DRG"
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","46061.86","34546.39","MEDICARE [2001]","HB NWH MEDICARE","24320.40","","Case rate ($24,320.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $22,722.22, add-ons for qualifying new technology services are included. If operating cost exceeds $67,864.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,632.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $22,630.08. The transfer operating threshold is the transfer adjustment factor * $22,722.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,690.31. The transfer capital threshold is the transfer adjustment factor * $1,690.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","23881.43","23881.43","23924.36","1 through 10","21676.63","24744.2558","other","Inpatient DRG"
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","39142.41","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14865.5994","","Fee schedule rate ($25,340.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14865.5994","25340.12","25340.12","1 through 10","9758.09","41810.79","case rate",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC","717","MS-DRG","","","","","","","","inpatient","","","46215.03","34661.27","MEDICARE [2001]","HB NWH MEDICARE","18009.28","","Case rate ($18,009.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,825.83, add-ons for qualifying new technology services are included. If operating cost exceeds $61,968.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,193.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,757.61. The transfer operating threshold is the transfer adjustment factor * $16,825.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,251.68. The transfer capital threshold is the transfer adjustment factor * $1,251.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17741.04","17741.04","17741.04","1 through 10","16051.57","18349.0395","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC","717","MS-DRG","","","","","","","","inpatient","","","46215.03","34661.27","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16051.57","","Case rate ($16,379.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,825.83, add-ons for qualifying new technology services are included. If operating cost exceeds $61,968.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,193.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $15,127.47. The transfer operating threshold is the transfer adjustment factor * $16,825.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,251.68. The transfer capital threshold is the transfer adjustment factor * $1,251.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15816.14","15816.14","15816.14","1 through 10","16051.57","18349.0395","other","Inpatient DRG"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","","","","inpatient","","","19596.03","14697.02","MEDICARE [2001]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11351.84","11351.84","11351.84","1 through 10","1154.79","10992.79","other","Inpatient Psych"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","36897.55","27673.16","MEDICARE [2001]","HB NWH MEDICARE","14599.87","","Case rate ($14,599.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,640.46, add-ons for qualifying new technology services are included. If operating cost exceeds $58,782.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,956.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,585.14. The transfer operating threshold is the transfer adjustment factor * $13,640.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,014.72. The transfer capital threshold is the transfer adjustment factor * $1,014.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14317.22","14317.22","14342.96","1 through 10","13012.77","15732.14","other","Inpatient DRG"
"Other Multiple Significant Trauma With McC","963","MS-DRG","","","","","","","","inpatient","","","44919.34","33689.50","MEDICARE [2001]","HB NWH MEDICARE","26042.74","","Case rate ($26,042.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,331.38, add-ons for qualifying new technology services are included. If operating cost exceeds $69,473.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,751.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $24,232.72. The transfer operating threshold is the transfer adjustment factor * $24,331.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,810.02. The transfer capital threshold is the transfer adjustment factor * $1,810.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25928.65","25928.65","25928.65","1 through 10","23211.74","27034.5482","other","Inpatient DRG"
"Other Multiple Significant Trauma With McC","963","MS-DRG","","","","","","","","inpatient","","","44919.34","33689.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","23211.74","","Case rate ($23,685.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,331.38, add-ons for qualifying new technology services are included. If operating cost exceeds $69,473.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,751.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,875.42. The transfer operating threshold is the transfer adjustment factor * $24,331.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,810.02. The transfer capital threshold is the transfer adjustment factor * $1,810.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23163.99","23163.99","23163.99","1 through 10","23211.74","27034.5482","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","26892.68","20169.51","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9282.33","","Case rate ($9,282.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,672.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,814.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,587.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,637.19. The transfer operating threshold is the transfer adjustment factor * $8,672.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.14. The transfer capital threshold is the transfer adjustment factor * $645.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9593.69","9593.69","9593.69","1 through 10","8273.29","10002.22","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","26892.68","20169.51","MEDICARE [2001]","HB NWH MEDICARE","9282.33","","Case rate ($9,282.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,672.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,814.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,587.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,637.19. The transfer operating threshold is the transfer adjustment factor * $8,672.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.14. The transfer capital threshold is the transfer adjustment factor * $645.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9749.68","9732.19","9749.68","1 through 10","8273.29","10002.22","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","26892.68","20169.51","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8273.29","","Case rate ($8,442.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,672.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,814.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,587.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,796.99. The transfer operating threshold is the transfer adjustment factor * $8,672.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.14. The transfer capital threshold is the transfer adjustment factor * $645.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8728.00","8728.00","8728.00","1 through 10","8273.29","10002.22","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","26892.68","20169.51","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8273.29","","Case rate ($8,442.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,672.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,814.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,587.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,796.99. The transfer operating threshold is the transfer adjustment factor * $8,672.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.14. The transfer capital threshold is the transfer adjustment factor * $645.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8731.99","8731.99","8731.99","1 through 10","8273.29","10002.22","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","51123.95","38342.96","MEDICARE [2001]","HB NWH MEDICARE","14704.65","","Case rate ($14,704.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,738.36, add-ons for qualifying new technology services are included. If operating cost exceeds $58,880.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,963.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,682.65. The transfer operating threshold is the transfer adjustment factor * $13,738.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,022.00. The transfer capital threshold is the transfer adjustment factor * $1,022.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15003.64","14976.72","34696.67","1 through 10","13106.17","15517.8188","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC","566","MS-DRG","","","","","","","","inpatient","","","17765.21","13323.91","MEDICARE [2001]","HB NWH MEDICARE","6491.87","","Case rate ($6,491.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,668.92, add-ons for qualifying new technology services are included. If operating cost exceeds $51,811.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,438.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,995.78. The transfer operating threshold is the transfer adjustment factor * $6,668.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.10. The transfer capital threshold is the transfer adjustment factor * $496.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7139.91","1300.85","7152.83","1 through 10","6362.03","7421.6945","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","152134.02","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","44242.29","","Fee schedule rate ($44,242.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44242.29","44242.29","44242.29","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","22902.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22330.71","","Standard inlier is a Case rate ($22,330.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,557, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,169.93) for the length of stay and the standard reimbursement.","17864.56","17864.56","17864.56","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","22902.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23987.64","","Standard inlier is a Case rate ($23,987.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,557, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,404.94) for the length of stay and the standard reimbursement.","22899.83","22899.83","22899.83","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","22902.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8909.1978","","Fee schedule rate ($21,201.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8909.1978","21201.12","21201.12","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","22902.71","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9354.6121","","Fee schedule rate ($22,261.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9354.6121","29790.99","29790.99","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","22902.71","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","9493.06","","Case rate ($10,227.27). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,657.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,582.64 and the sum of the standard inlier and any outlier amount.","10253.58","10253.58","10253.58","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","14056.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11377.41","","Standard inlier is a Case rate ($11,377.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,320, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,615.07) for the length of stay and the standard reimbursement.","11377.41","11377.41","11377.41","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","14056.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12221.61","","Standard inlier is a Case rate ($12,221.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,320, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,734.81) for the length of stay and the standard reimbursement.","12221.60","12221.60","12221.60","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","14056.22","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","4689.41","","Case rate ($5,052.10). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,482.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5065.09","5065.09","5065.09","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14424.63","","Standard inlier is a Case rate ($14,424.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,047.63) for the length of stay and the standard reimbursement.","31977.28","31977.28","31977.28","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15494.93","","Standard inlier is a Case rate ($15,494.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,199.44) for the length of stay and the standard reimbursement.","15494.92","15494.92","15494.92","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8909.1978","","Fee schedule rate ($10,327.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8909.1978","12149.26","12149.26","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9354.6121","","Fee schedule rate ($10,843.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9354.6121","19772.73","19772.73","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","10843.07","","Fee schedule rate ($10,843.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12756.66","12756.66","12756.66","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","MASSHEALTH [3001]","HB NWH MEDICAID","5710.69","","Case rate ($6,152.36). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,582.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4043.02","4043.02","6168.19","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19047.27","","Fee schedule rate ($19,047.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15440.98","15440.98","15440.98","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","20060.82","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5710.69","","Case rate ($6,152.36). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,582.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6168.19","6168.19","6168.19","1 through 10","4624.04","44242.29","case rate",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","52055.35","39041.51","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","18544.65","","Case rate ($18,004.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,495.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,637.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,317.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,628.62. The transfer operating threshold is the transfer adjustment factor * $18,495.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.89. The transfer capital threshold is the transfer adjustment factor * $1,375.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15942.78","15942.78","15942.78","1 through 10","17644.42","19893.7013","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","52055.35","39041.51","MEDICARE [2001]","HB NWH MEDICARE","18004.51","","Case rate ($18,004.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,495.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,637.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,317.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,628.62. The transfer operating threshold is the transfer adjustment factor * $18,495.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.89. The transfer capital threshold is the transfer adjustment factor * $1,375.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19200.01","17014.87","19234.53","15","17644.42","19893.7013","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","52055.35","39041.51","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","17644.42","","Case rate ($18,004.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,495.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,637.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,317.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,628.62. The transfer operating threshold is the transfer adjustment factor * $18,495.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.89. The transfer capital threshold is the transfer adjustment factor * $1,375.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17158.78","17158.78","17185.34","1 through 10","17644.42","19893.7013","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","52055.35","39041.51","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","17644.42","","Case rate ($18,004.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,495.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,637.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,317.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,628.62. The transfer operating threshold is the transfer adjustment factor * $18,495.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.89. The transfer capital threshold is the transfer adjustment factor * $1,375.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19307.67","19307.67","19307.67","1 through 10","17644.42","19893.7013","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","52055.35","39041.51","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17644.42","","Case rate ($18,004.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,495.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,637.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,317.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,628.62. The transfer operating threshold is the transfer adjustment factor * $18,495.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.89. The transfer capital threshold is the transfer adjustment factor * $1,375.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17164.19","17164.19","17164.19","1 through 10","17644.42","19893.7013","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","46255.72","34691.79","MEDICARE [2001]","HB NWH MEDICARE","27611.07","","Case rate ($27,611.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,364.06, add-ons for qualifying new technology services are included. If operating cost exceeds $73,506.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,051.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,501.06. The transfer operating threshold is the transfer adjustment factor * $28,364.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,110.01. The transfer capital threshold is the transfer adjustment factor * $2,110.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19133.09","19133.09","19133.09","1 through 10","27058.85","30580.7436","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","48271.86","36203.89","MEDICARE [2001]","HB NWH MEDICARE","13313.85","","Case rate ($13,313.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,676.94, add-ons for qualifying new technology services are included. If operating cost exceeds $58,819.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,959.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,296.42. The transfer operating threshold is the transfer adjustment factor * $13,676.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.43. The transfer capital threshold is the transfer adjustment factor * $1,017.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14246.58","14246.58","14246.58","1 through 10","13047.57","15196.4263","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","48271.86","36203.89","MOLINA [1014]","HB NWH MEDICARE","13313.85","","Case rate ($13,313.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,676.94, add-ons for qualifying new technology services are included. If operating cost exceeds $58,819.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,959.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,296.42. The transfer operating threshold is the transfer adjustment factor * $13,676.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.43. The transfer capital threshold is the transfer adjustment factor * $1,017.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25748.31","25748.31","25748.31","1 through 10","13047.57","15196.4263","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","31193.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27203.02","","Standard inlier is a Case rate ($27,203.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,628, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,861.35) for the length of stay and the standard reimbursement.","27203.02","27203.02","27203.02","1 through 10","10368.11","203875.59","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","31193.37","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","10368.11","","Case rate ($11,170.01). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,600.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11198.73","11198.73","11198.73","1 through 10","10368.11","203875.59","case rate",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","40214.06","30160.54","MEDICARE [2001]","HB NWH MEDICARE","11597.20","","Case rate ($11,597.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,835.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,977.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,748.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,791.17. The transfer operating threshold is the transfer adjustment factor * $10,835.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.03. The transfer capital threshold is the transfer adjustment factor * $806.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11407.18","11407.18","11427.69","1 through 10","10336.51","11819.3328","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","69348.86","52011.64","MEDICARE [2001]","HB NWH MEDICARE","17282.80","","Case rate ($17,282.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,754.13, add-ons for qualifying new technology services are included. If operating cost exceeds $62,896.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,262.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,962.07. The transfer operating threshold is the transfer adjustment factor * $17,754.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,320.73. The transfer capital threshold is the transfer adjustment factor * $1,320.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18069.96","18069.96","18102.46","1 through 10","16937.14","18722.8437","other","Inpatient Replacement Plans DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","69348.86","52011.64","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16937.14","","Case rate ($17,282.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,754.13, add-ons for qualifying new technology services are included. If operating cost exceeds $62,896.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,262.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,962.07. The transfer operating threshold is the transfer adjustment factor * $17,754.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,320.73. The transfer capital threshold is the transfer adjustment factor * $1,320.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16175.84","16175.84","16175.84","1 through 10","16937.14","18722.8437","other","Inpatient DRG"
"Other Non-Hypovolemic Electrolyte Disorders,EXTREME","425","DRG","","","","","","","","inpatient","","","30279.36","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8369.8386","","Fee schedule rate ($47,979.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8369.8386","47979.52","47979.52","1 through 10","4103.38","79165.47","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","28219.02","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8369.8386","","Fee schedule rate ($19,809.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8369.8386","19809.72","19809.72","1 through 10","4103.38","79165.47","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MINOR","425","DRG","","","","","","","","inpatient","","","14106.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11134.02","","Standard inlier is a Case rate ($11,134.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,280, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,580.43) for the length of stay and the standard reimbursement.","11134.01","11134.01","11134.01","1 through 10","4103.38","79165.47","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","12568.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12691.42","","Standard inlier is a Case rate ($12,691.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,669, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,801.60) for the length of stay and the standard reimbursement.","12691.41","12691.41","12691.41","1 through 10","4103.38","79165.47","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","12568.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13633.11","","Standard inlier is a Case rate ($13,633.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,669, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,935.16) for the length of stay and the standard reimbursement.","13633.11","13633.11","13633.11","1 through 10","4103.38","79165.47","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","12568.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8369.8386","","Fee schedule rate ($11,719.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8369.8386","11719.34","11719.34","1 through 10","4103.38","79165.47","case rate",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","43307.02","32480.26","MEDICARE [2001]","HB NWH MEDICARE","19006.67","","Case rate ($19,006.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,757.68, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,262.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $17,685.68. The transfer operating threshold is the transfer adjustment factor * $17,757.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,321.00. The transfer capital threshold is the transfer adjustment factor * $1,321.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19251.55","19251.55","19286.16","1 through 10","16940.53","19947.1019","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","48053.82","36040.36","MEDICARE [2001]","HB NWH MEDICARE","36573.95","","Case rate ($36,573.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $34,170.56, add-ons for qualifying new technology services are included. If operating cost exceeds $79,312.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,483.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $34,031.99. The transfer operating threshold is the transfer adjustment factor * $34,170.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,541.96. The transfer capital threshold is the transfer adjustment factor * $2,541.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27599.64","27599.64","27599.64","1 through 10","32598.14","39410.41","other","Inpatient DRG"
"Other O.R. Procedures For Injuries Without Cc/McC","909","MS-DRG","","","","","","","","inpatient","","","30778.94","23084.20","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11714.34","","Case rate ($11,373.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,683.30, add-ons for qualifying new technology services are included. If operating cost exceeds $56,825.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,811.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,504.01. The transfer operating threshold is the transfer adjustment factor * $11,683.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $869.12. The transfer capital threshold is the transfer adjustment factor * $869.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6155.00","6155.00","6155.00","1 through 10","11145.69","12542.2187","other","Inpatient DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","","","","inpatient","","","33303.49","24977.62","MEDICARE [2001]","HB NWH MEDICARE","16105.37","","Case rate ($16,105.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,544.59, add-ons for qualifying new technology services are included. If operating cost exceeds $61,686.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,172.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,874.62. The transfer operating threshold is the transfer adjustment factor * $16,544.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,230.76. The transfer capital threshold is the transfer adjustment factor * $1,230.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16988.62","16988.62","16988.62","1 through 10","15783.26","17602.42","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC","804","MS-DRG","","","","","","","","inpatient","","","36824.44","27618.33","MEDICARE [2001]","HB NWH MEDICARE","12917.53","","Case rate ($12,917.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,068.68, add-ons for qualifying new technology services are included. If operating cost exceeds $57,210.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,839.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $12,019.74. The transfer operating threshold is the transfer adjustment factor * $12,068.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.79. The transfer capital threshold is the transfer adjustment factor * $897.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10551.89","10551.89","10551.89","1 through 10","10933.2784","12917.53","other","Inpatient DRG"
"Other Peripheral Vascular And Circulatory Procedures,MINOR","180","DRG","","","","","","","","inpatient","","","22219.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30065.53","","Standard inlier is a Case rate ($30,065.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,267.67) for the length of stay and the standard reimbursement.","30065.52","30065.52","30065.52","1 through 10","11288.86","40008.36","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31227.21","","Standard inlier is a Case rate ($31,227.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,432.82) for the length of stay and the standard reimbursement.","31227.20","31227.20","31227.20","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","33544.25","","Standard inlier is a Case rate ($33,544.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,761.46) for the length of stay and the standard reimbursement.","32022.29","32022.29","32022.29","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($42,339.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","40708.24","40708.24","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10374.4064","","Fee schedule rate ($44,456.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10374.4064","69473.24","69473.24","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","MASSHEALTH [3001]","HB NWH MEDICAID","12895.03","","Case rate ($13,892.36). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,322.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13928.09","4914.57","13928.09","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13449.10","","Fee schedule rate ($13,449.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13449.10","13449.10","13449.10","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","28522.83","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28666.02","","Fee schedule rate ($28,666.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28666.02","28666.02","28666.02","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20761.75","","Standard inlier is a Case rate ($20,761.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,948, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,947.21) for the length of stay and the standard reimbursement.","20761.75","19818.30","20761.75","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22302.26","","Standard inlier is a Case rate ($22,302.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,948, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,165.71) for the length of stay and the standard reimbursement.","3799.55","2462.78","22302.26","12","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($23,358.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","23358.55","23358.56","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10374.4064","","Fee schedule rate ($24,526.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10374.4064","24526.36","24526.36","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","25694.17","","Fee schedule rate ($25,694.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24703.28","24703.28","24703.28","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","MASSHEALTH [3001]","HB NWH MEDICAID","7620.72","","Case rate ($8,210.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,640.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8231.24","8231.24","10682.65","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","17323.08","","Fee schedule rate ($17,323.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17323.08","17323.08","17323.08","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","7620.72","","Case rate ($8,210.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,640.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10289.05","10289.05","10289.05","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","16124.56","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7620.72","","Case rate ($8,210.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,640.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10289.05","10289.05","10289.05","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10798.86","","Standard inlier is a Case rate ($10,798.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,726, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,532.94) for the length of stay and the standard reimbursement.","10308.38","10308.38","10798.85","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11600.13","","Standard inlier is a Case rate ($11,600.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,726, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,646.59) for the length of stay and the standard reimbursement.","11073.26","11072.84","11600.12","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($9,880.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","9880.44","9880.44","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10374.4064","","Fee schedule rate ($10,374.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10374.4064","9974.48","9974.48","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10868.38","","Fee schedule rate ($10,868.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10449.24","10449.24","10449.24","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","MASSHEALTH [3001]","HB NWH MEDICAID","3946.87","","Case rate ($4,252.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,682.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5328.83","4426.15","5328.83","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8706.59","","Fee schedule rate ($8,706.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8706.59","8706.59","8706.59","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","12705.76","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3946.87","","Case rate ($4,252.13). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,682.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5328.84","5328.84","5328.84","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14978.67","","Standard inlier is a Case rate ($14,978.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,126.28) for the length of stay and the standard reimbursement.","14298.92","14298.92","14298.92","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16090.07","","Standard inlier is a Case rate ($16,090.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,283.92) for the length of stay and the standard reimbursement.","16090.07","15358.70","16090.07","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($13,868.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","13334.56","13868.96","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10374.4064","","Fee schedule rate ($14,562.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10374.4064","14562.32","14562.32","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","MASSHEALTH [3001]","HB NWH MEDICAID","5101.81","","Case rate ($5,496.39). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,926.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5510.52","5510.52","5510.52","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5644.92","","Fee schedule rate ($5,644.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5644.92","5644.92","5644.92","1 through 10","3471.99","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","17159.27","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5101.81","","Case rate ($5,496.39). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,926.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5510.53","315.30","6304.47","1 through 10","3471.99","69859.85","case rate",""
"Other Respiratory And Chest Procedures,EXTREME","121","DRG","","","","","","","","inpatient","","","50443.27","","MASSHEALTH [3001]","HB NWH MEDICAID","18564.59","","Case rate ($20,000.41). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,430.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50663.28","50663.28","50663.28","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","31735.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32046.01","","Standard inlier is a Case rate ($32,046.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,549.06) for the length of stay and the standard reimbursement.","32046.00","32046.00","32046.00","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","31735.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34423.80","","Standard inlier is a Case rate ($34,423.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,886.31) for the length of stay and the standard reimbursement.","34423.80","34423.80","34423.80","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","48202.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41430.35","","Fee schedule rate ($41,430.35). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,792.84) multiplied by length of stay and the outlier percent (100%).","56243.12","56243.12","56243.12","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","48202.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44504.46","","Fee schedule rate ($44,504.46). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,149.43) multiplied by length of stay and the outlier percent (100%).","5149.43","4914.52","42485.62","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","48202.26","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24669.8208","","Fee schedule rate ($34,911.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24669.8208","34911.78","34911.78","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","48202.26","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","33348.423","","Fee schedule rate ($34,911.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33348.423","34911.78","34911.78","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","48202.26","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","40622.89","","Fee schedule rate ($40,622.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40622.89","40622.89","40622.89","1 through 10","11623.57","233120.9","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","44604.42","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10836.0839","","Fee schedule rate ($41,575.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10836.0839","41575.60","41575.60","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","44604.42","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8862.1561","","Fee schedule rate ($41,575.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8862.1561","41575.60","41575.60","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","44604.42","","MASSHEALTH [3001]","HB NWH MEDICAID","17156.05","","Case rate ($18,482.94). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $60,912.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3852.49","3852.49","3852.49","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","44604.42","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","42094.74","","Fee schedule rate ($42,094.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42094.74","42094.74","42094.74","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","49460.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26173.36","","Standard inlier is a Case rate ($26,173.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,643, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,715.20) for the length of stay and the standard reimbursement.","24983.66","24983.66","24983.66","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","49460.87","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10836.0839","","Fee schedule rate ($27,146.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10836.0839","27146.64","27146.64","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","49460.87","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8862.1561","","Fee schedule rate ($27,146.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8862.1561","27146.64","27146.64","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","49460.87","","MASSHEALTH [3001]","HB NWH MEDICAID","10971.28","","Case rate ($11,819.83). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,249.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,457.35 and the sum of the standard inlier and any outlier amount.","11850.22","11850.22","11850.22","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","49460.87","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25911.14","","Fee schedule rate ($25,911.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25911.14","25911.14","25911.14","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","19253.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12908.93","","Standard inlier is a Case rate ($12,908.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,976, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,832.37) for the length of stay and the standard reimbursement.","12908.92","12322.15","12908.92","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","19253.27","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11352.04","","Fee schedule rate ($11,352.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11352.04","11352.04","11352.04","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","19253.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12614.37","","Fee schedule rate ($12,614.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10555.96","10555.96","10555.96","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","19253.27","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5122.37","","Case rate ($5,518.54). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,948.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5532.74","5532.74","5532.74","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","17061.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17028.12","","Standard inlier is a Case rate ($17,028.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,417.21) for the length of stay and the standard reimbursement.","17028.11","17028.11","17028.11","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","17061.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18291.60","","Standard inlier is a Case rate ($18,291.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,596.41) for the length of stay and the standard reimbursement.","17460.16","17460.16","17461.37","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","17061.71","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10836.0839","","Fee schedule rate ($16,066.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10836.0839","20571.30","20571.30","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","17061.71","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8862.1561","","Fee schedule rate ($16,066.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8862.1561","20571.30","20571.30","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","27895.99","20921.99","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","17442.49","","Case rate ($17,442.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,296.28, add-ons for qualifying new technology services are included. If operating cost exceeds $61,438.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,230.19. The transfer operating threshold is the transfer adjustment factor * $16,296.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.28. The transfer capital threshold is the transfer adjustment factor * $1,212.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16284.28","16284.28","16284.28","1 through 10","15546.39","18795.22","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","27895.99","20921.99","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9799.06","9799.06","9799.06","1 through 10","15546.39","18795.22","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","27895.99","20921.99","MEDICARE [2001]","HB NWH MEDICARE","17442.49","","Case rate ($17,442.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,296.28, add-ons for qualifying new technology services are included. If operating cost exceeds $61,438.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,230.19. The transfer operating threshold is the transfer adjustment factor * $16,296.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.28. The transfer capital threshold is the transfer adjustment factor * $1,212.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18049.88","18017.25","18049.88","1 through 10","15546.39","18795.22","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","27895.99","20921.99","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","15546.39","","Case rate ($15,863.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,296.28, add-ons for qualifying new technology services are included. If operating cost exceeds $61,438.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,651.36. The transfer operating threshold is the transfer adjustment factor * $16,296.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.28. The transfer capital threshold is the transfer adjustment factor * $1,212.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29723.05","29723.05","29723.05","1 through 10","15546.39","18795.22","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","27895.99","20921.99","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15546.39","","Case rate ($15,863.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,296.28, add-ons for qualifying new technology services are included. If operating cost exceeds $61,438.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,154.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,651.36. The transfer operating threshold is the transfer adjustment factor * $16,296.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.28. The transfer capital threshold is the transfer adjustment factor * $1,212.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16124.10","16124.10","16124.10","1 through 10","15546.39","18795.22","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","26100.57","19575.43","MEDICARE [2001]","HB NWH MEDICARE","8153.61","","Case rate ($8,153.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,375.98, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,565.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,530.53. The transfer operating threshold is the transfer adjustment factor * $8,375.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $623.09. The transfer capital threshold is the transfer adjustment factor * $623.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8645.12","7216.92","8660.65","1 through 10","7990.54","8957.4562","other","Inpatient Replacement Plans DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","26100.57","19575.43","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7990.54","","Case rate ($8,153.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,375.98, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,565.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,530.53. The transfer operating threshold is the transfer adjustment factor * $8,375.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $623.09. The transfer capital threshold is the transfer adjustment factor * $623.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7754.50","7754.50","7754.50","1 through 10","7990.54","8957.4562","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","26100.57","19575.43","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7990.54","","Case rate ($8,153.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,375.98, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,565.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,530.53. The transfer operating threshold is the transfer adjustment factor * $8,375.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $623.09. The transfer capital threshold is the transfer adjustment factor * $623.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7757.98","7757.98","7757.98","1 through 10","7990.54","8957.4562","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","45037.52","33778.14","MEDICARE [2001]","HB NWH MEDICARE","17179.55","","Case rate ($17,179.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,050.63, add-ons for qualifying new technology services are included. If operating cost exceeds $61,192.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,135.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $15,985.54. The transfer operating threshold is the transfer adjustment factor * $16,050.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,194.01. The transfer capital threshold is the transfer adjustment factor * $1,194.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17439.10","17439.10","17439.10","1 through 10","15312.03","18511.9","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","70426.60","52819.95","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","33354.65","","Case rate ($32,383.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,266.29, add-ons for qualifying new technology services are included. If operating cost exceeds $78,408.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,416.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $29,908.47. The transfer operating threshold is the transfer adjustment factor * $33,266.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,474.69. The transfer capital threshold is the transfer adjustment factor * $2,474.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","34508.06","34508.06","34508.06","1 through 10","31735.5","38367.49","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","70426.60","52819.95","MEDICARE [2001]","HB NWH MEDICARE","32383.16","","Case rate ($32,383.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $33,266.29, add-ons for qualifying new technology services are included. If operating cost exceeds $78,408.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,416.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $29,908.47. The transfer operating threshold is the transfer adjustment factor * $33,266.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,474.69. The transfer capital threshold is the transfer adjustment factor * $2,474.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36747.92","36747.92","36747.92","1 through 10","31735.5","38367.49","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","40442.39","30331.79","MEDICARE [2001]","HB NWH MEDICARE","11838.39","","Case rate ($11,838.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,161.23, add-ons for qualifying new technology services are included. If operating cost exceeds $57,303.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,846.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,933.71. The transfer operating threshold is the transfer adjustment factor * $12,161.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $904.68. The transfer capital threshold is the transfer adjustment factor * $904.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12945.09","12945.09","12945.09","1 through 10","11601.62","13388.7171","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","23449.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10166.37","","Standard inlier is a Case rate ($10,166.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,443.16) for the length of stay and the standard reimbursement.","19874.46","19874.46","19874.46","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","23449.09","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","21080.82","","Fee schedule rate ($21,080.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21080.82","21080.82","21080.82","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","9388.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10920.71","","Standard inlier is a Case rate ($10,920.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,550.15) for the length of stay and the standard reimbursement.","10921.08","10921.08","10921.08","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","9388.40","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8895.5184","","Fee schedule rate ($8,895.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8895.5184","7561.33","7561.33","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","9388.40","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11025.45","","Fee schedule rate ($11,025.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11025.45","11025.45","11025.45","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","12558.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8895.5184","","Fee schedule rate ($12,473.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8895.5184","12473.66","12473.66","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","12558.95","","MASSHEALTH [3001]","HB NWH MEDICAID","6029.41","","Case rate ($6,495.73). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,925.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4192.00","4192.00","4192.00","1 through 10","4396.86","31850.62","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","34900.41","26175.31","MEDICARE [2001]","HB NWH MEDICARE","16461.28","","Case rate ($16,461.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,379.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,521.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,086.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,317.19. The transfer operating threshold is the transfer adjustment factor * $15,379.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.09. The transfer capital threshold is the transfer adjustment factor * $1,144.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16952.22","16921.80","16952.22","1 through 10","14671.84","17533.197","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","29664.49","22248.37","MEDICARE [2001]","HB NWH MEDICARE","28058.12","","Case rate ($28,058.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,823.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,965.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,086.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $25,913.95. The transfer operating threshold is the transfer adjustment factor * $28,823.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,144.17. The transfer capital threshold is the transfer adjustment factor * $2,144.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31164.19","31164.19","31164.19","1 through 10","27496.96","32232.2066","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","29664.49","22248.37","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","27496.96","","Case rate ($28,058.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,823.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,965.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,086.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $25,913.95. The transfer operating threshold is the transfer adjustment factor * $28,823.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,144.17. The transfer capital threshold is the transfer adjustment factor * $2,144.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7217.23","7217.23","7217.23","1 through 10","27496.96","32232.2066","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","18608.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17974.40","","Standard inlier is a Case rate ($17,974.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,087, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,551.54) for the length of stay and the standard reimbursement.","17974.39","17974.39","17974.39","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","18608.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19308.09","","Standard inlier is a Case rate ($19,308.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,087, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,740.70) for the length of stay and the standard reimbursement.","10587.70","10587.70","10587.70","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","18608.01","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","18428.16","","Fee schedule rate ($18,428.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10717.70","10717.70","10717.70","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","18608.01","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","7136.36","","Case rate ($7,688.30). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,118.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7708.07","7708.07","7708.07","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","35221.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26676.34","","Standard inlier is a Case rate ($26,676.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,125, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,786.59) for the length of stay and the standard reimbursement.","26676.34","26676.34","26676.34","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","35221.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15211.4928","","Fee schedule rate ($23,999.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15211.4928","13941.26","13941.26","1 through 10","7136.36","132490.6","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","35221.95","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","9319.42","","Case rate ($10,040.21). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,470.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10066.03","10066.03","10066.03","1 through 10","7136.36","132490.6","case rate",""
"Other Small And Large Bowel Procedures,MAJOR","223","DRG","","","","","","","","inpatient","","","20160.31","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84182.76","","Fee schedule rate ($84,182.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","98652.14","98652.14","98652.14","1 through 10","9237.17","88429.17","case rate",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","28147.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26681.61","","Standard inlier is a Case rate ($26,681.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,130, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,787.34) for the length of stay and the standard reimbursement.","26681.60","26681.60","26681.60","1 through 10","9237.17","88429.17","case rate",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","28147.81","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23118.186","","Fee schedule rate ($23,118.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23118.186","23118.18","23118.18","1 through 10","9237.17","88429.17","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","28758.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43425.87","","Standard inlier is a Case rate ($43,425.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,164.47) for the length of stay and the standard reimbursement.","37576.59","37576.59","37576.59","1 through 10","9237.17","88429.17","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","28758.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46648.05","","Standard inlier is a Case rate ($46,648.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,621.49) for the length of stay and the standard reimbursement.","40364.75","40364.75","40364.75","1 through 10","9237.17","88429.17","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","28758.88","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","33839.00","","Fee schedule rate ($33,839.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33839.00","33839.00","33839.00","1 through 10","9237.17","88429.17","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MAJOR","222","DRG","","","","","","","","inpatient","","","67838.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16937.0514","","Fee schedule rate ($51,774.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16937.0514","51774.58","51774.58","1 through 10","11975.32","85427.25","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MAJOR","222","DRG","","","","","","","","inpatient","","","67838.69","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17783.8173","","Fee schedule rate ($54,363.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17783.8173","54363.04","54363.04","1 through 10","11975.32","85427.25","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MODERATE","222","DRG","","","","","","","","inpatient","","","52993.92","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","32709.46","","Standard inlier is a Case rate ($32,709.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $42,886, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,642.97) for the length of stay and the standard reimbursement.","31222.66","31222.66","31222.66","1 through 10","11975.32","85427.25","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","88872.54","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","25279.42","","Case rate ($27,234.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $69,664.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27304.62","27304.62","27304.62","1 through 10","17808.34","128552.19","case rate",""
"Other Upper Vascular Procedures,MINOR","182","DRG","","","","","","","","inpatient","","","74370.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","44568.27","","Standard inlier is a Case rate ($44,568.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $57,371, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,326.64) for the length of stay and the standard reimbursement.","44568.27","44568.27","44568.27","1 through 10","17808.34","128552.19","case rate",""
"Other Upper Vascular Procedures,MODERATE","182","DRG","","","","","","","","inpatient","","","57426.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","51988.58","","Standard inlier is a Case rate ($51,988.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $61,297, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,379.56) for the length of stay and the standard reimbursement.","51988.58","51988.58","51988.58","1 through 10","17808.34","128552.19","case rate",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","72020.31","54015.23","MEDICARE [2001]","HB NWH MEDICARE","24726.22","","Case rate ($24,726.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $23,101.38, add-ons for qualifying new technology services are included. If operating cost exceeds $68,243.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,660.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $23,007.70. The transfer operating threshold is the transfer adjustment factor * $23,101.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.52. The transfer capital threshold is the transfer adjustment factor * $1,718.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24366.28","24366.28","24410.09","1 through 10","22038.33","25246.617","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","72020.31","54015.23","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","22038.33","","Case rate ($22,488.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $23,101.38, add-ons for qualifying new technology services are included. If operating cost exceeds $68,243.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,660.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $20,769.57. The transfer operating threshold is the transfer adjustment factor * $23,101.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,718.52. The transfer capital threshold is the transfer adjustment factor * $1,718.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21761.60","21761.60","21761.60","1 through 10","22038.33","25246.617","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","120760.84","90570.63","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","30222.36","","Case rate ($30,222.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,046.58, add-ons for qualifying new technology services are included. If operating cost exceeds $76,188.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,251.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $27,912.81. The transfer operating threshold is the transfer adjustment factor * $31,046.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.56. The transfer capital threshold is the transfer adjustment factor * $2,309.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29581.94","29581.94","29581.94","1 through 10","29617.91","33923.2256","other","Inpatient Replacement Plans DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","120760.84","90570.63","MEDICARE [2001]","HB NWH MEDICARE","30222.36","","Case rate ($30,222.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,046.58, add-ons for qualifying new technology services are included. If operating cost exceeds $76,188.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,251.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $27,912.81. The transfer operating threshold is the transfer adjustment factor * $31,046.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.56. The transfer capital threshold is the transfer adjustment factor * $2,309.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32740.33","32740.33","32740.33","1 through 10","29617.91","33923.2256","other","Inpatient Replacement Plans DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","120760.84","90570.63","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","29617.91","","Case rate ($30,222.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,046.58, add-ons for qualifying new technology services are included. If operating cost exceeds $76,188.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,251.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $27,912.81. The transfer operating threshold is the transfer adjustment factor * $31,046.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.56. The transfer capital threshold is the transfer adjustment factor * $2,309.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29115.53","29115.53","29115.53","1 through 10","29617.91","33923.2256","other","Inpatient DRG"
"Other Vascular Procedures,MINOR","173","DRG","","","","","","","","inpatient","","","61217.79","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29445.8856","","Fee schedule rate ($29,445.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29445.8856","29445.88","29445.88","1 through 10","24184.14","239940.5","case rate",""
"Other Vascular Procedures,MINOR","173","DRG","","","","","","","","inpatient","","","61217.79","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","32390.17","","Fee schedule rate ($32,390.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32390.17","32390.17","32390.17","1 through 10","24184.14","239940.5","case rate",""
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","19293.62","14470.21","MEDICARE [2001]","HB NWH MEDICARE","10242.50","","Case rate ($10,242.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,521.82, add-ons for qualifying new technology services are included. If operating cost exceeds $55,664.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,724.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,459.77. The transfer operating threshold is the transfer adjustment factor * $10,521.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $782.72. The transfer capital threshold is the transfer adjustment factor * $782.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10830.73","10830.73","10850.19","1 through 10","10037.65","11222.0372","other","Inpatient Replacement Plans DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","13158.25","9868.69","MEDICARE [2001]","HB NWH MEDICARE","6395.71","","Case rate ($6,395.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,570.13, add-ons for qualifying new technology services are included. If operating cost exceeds $51,712.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,430.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,906.96. The transfer operating threshold is the transfer adjustment factor * $6,570.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $488.75. The transfer capital threshold is the transfer adjustment factor * $488.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6804.80","6792.59","6804.80","1 through 10","6267.8","7577.62","other","Inpatient Replacement Plans DRG"
"PACEMAKER ACCOLADE 12.2CC 4.45CM 5.02CM .75CM 24.8G DUAL RA IS1-RVIS1 CONNECTOR","SUP-ITM-10140406","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","4826.00","3619.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2861.82","59.3","","2828.04","2828.04","2828.04","1 through 10","2413","3786","percent of total billed charges",""
"PACEMAKER DUAL CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY DR RF","SUP-ITM-10132828","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","7824.00","5868.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4639.63","59.3","","2828.04","2828.04","2828.04","1 through 10","3912","6137.93","percent of total billed charges",""
"Pacemaker Dual Chamber Rate Responsive T3","PX-27000123","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","7129.93","5347.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","4228.05","59.3","","2828.04","2828.04","2828.04","1 through 10","3564.97","5593.43","percent of total billed charges",""
"PACEMAKER ESSENTIO 13.2CC 4.81CM 4.45CM .75CM 23.6G SR SINGLE CHAMBER RA/RV IS1 CONNECTOR","SUP-ITM-10140407","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","4197.50","3148.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2489.12","59.3","","2828.04","2828.04","2828.04","1 through 10","2098.75","3292.94","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","85.72","64.29","WELLPOINT [1015]","HB CH WELLPOINT","66.78","77.91","","582.67","582.67","582.67","1 through 10","38.1","66.78","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","85.72","64.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","67.25","78.45","","394.74","331.66","1115.07","1 through 10","42.86","67.25","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","AETNA [1001]","HB CH AETNA HMO / PPO","813.29","58.3","","416.75","416.75","416.75","1 through 10","620.08","1086.84","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","827.24","59.3","","7893.60","423.68","7893.60","1 through 10","697.5","1094.38","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1094.38","78.45","","555.84","329.40","555.84","1 through 10","697.5","1094.38","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","both","","","2739.00","2054.25","AETNA [1001]","HB CH AETNA HMO / PPO","1596.84","58.3","","416.75","416.75","416.75","1 through 10","1217.49","2133.95","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2739.00","2054.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1624.23","59.3","","7893.60","423.68","7893.60","1 through 10","1369.5","2148.75","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2739.00","2054.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2148.75","78.45","","555.84","329.40","555.84","1 through 10","1369.5","2148.75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1530.90","1160.93","1884.08","89","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","5253.92","5253.92","5253.92","1 through 10","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","12181.47","12181.47","12181.47","1 through 10","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","1350.68","1350.68","1350.68","1 through 10","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1910.74","891.94","1910.74","1 through 10","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","1829.79","1561.50","2617.12","88","33.34","58.43","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1359.46","1201.30","1689.00","61","37.5","58.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","1718.92","1718.92","1718.92","1 through 10","37.5","58.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1910.74","1019.06","2344.84","74","37.5","58.84","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","AETNA [1001]","HB CH AETNA HMO / PPO","640.13","58.3","","464.71","67.87","1012.10","221","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","640.13","58.3","","293.04","293.04","293.04","11","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","581.94","53","","983.89","983.89","983.89","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","636.84","58","","677.18","677.18","677.18","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","686.25","62.5","","46.58","46.58","46.58","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","801.54","73","","747.15","747.15","747.15","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.06","44.45","","1141.67","481.21","1141.67","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.06","44.45","","76.54","76.54","76.54","1 through 10","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","WELLPOINT [1015]","HB CH WELLPOINT","855.45","77.91","","273.64","94.28","1367.51","138","488.06","855.45","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.11","59.3","","720.78","230.14","2010.94","427","549","861.38","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","651.11","59.3","","344.45","344.45","344.45","1 through 10","549","861.38","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","861.38","78.45","","1120.13","1120.13","1120.13","1 through 10","549","861.38","percent of total billed charges",""
"PACK SCREW 2.2X18MM SHORT BONE SPEEDTIP TITANIUM CANNULATED COMPRESSION HEXADRIVE THREAD","SUP-ITM-10185759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","861.38","78.45","","456.17","105.33","1284.66","242","549","861.38","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","AETNA [1001]","HB CH AETNA HMO / PPO","2221.23","58.3","","464.71","67.87","1012.10","221","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2221.23","58.3","","293.04","293.04","293.04","11","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2019.30","53","","983.89","983.89","983.89","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2209.80","58","","677.18","677.18","677.18","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2381.25","62.5","","46.58","46.58","46.58","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2781.30","73","","747.15","747.15","747.15","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.55","44.45","","1141.67","481.21","1141.67","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.55","44.45","","76.54","76.54","76.54","1 through 10","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.00","2857.50","WELLPOINT [1015]","HB CH WELLPOINT","2968.37","77.91","","273.64","94.28","1367.51","138","1693.55","2968.37","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.00","2857.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2259.33","59.3","","720.78","230.14","2010.94","427","1905","2988.95","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.00","2857.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2259.33","59.3","","344.45","344.45","344.45","1 through 10","1905","2988.95","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.00","2857.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2988.95","78.45","","1120.13","1120.13","1120.13","1 through 10","1905","2988.95","percent of total billed charges",""
"PACK SCREW CANNULATED","SUP-ITM-10312154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.00","2857.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2988.95","78.45","","456.17","105.33","1284.66","242","1905","2988.95","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","103.19","103.19","11","27.63","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","177.84","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","118.56","63.4","","18.89","18.89","21.46","1 through 10","27.63","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","MEDICARE [2001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","182.00","1 through 10","27.63","177.84","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB NWH TRICARE","27.63","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","58.16","58.16","58.16","1 through 10","27.63","177.84","other","Tricare OPPS"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","177.84","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","177.84","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","187.00","140.25","WELLPOINT [1015]","HB CH WELLPOINT","145.69","77.91","","325.34","143.34","325.34","15","27.63","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","187.00","140.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.89","59.3","","319.95","106.65","1152.07","54","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","187.00","140.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","113.14","60.5","","21.46","18.89","21.46","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","187.00","140.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","113.14","60.5","","18.03","18.03","18.03","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.12","44.45","","139.92","139.92","139.92","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","146.70","78.45","","139.92","139.90","139.92","21","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","187.00","140.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","29.95","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","187.00","140.25","MEDICARE [2001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","182.00","1 through 10","27.63","29.95","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB NWH TRICARE","27.63","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","58.16","58.16","58.16","1 through 10","27.63","29.95","other","Tricare OPPS"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","187.00","140.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","29.95","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","29.95","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","103.19","103.19","11","75.88","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","187.00","140.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","118.56","63.4","","18.89","18.89","21.46","1 through 10","75.88","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","187.00","140.25","WELLPOINT [1015]","HB CH WELLPOINT","145.69","77.91","","325.34","143.34","325.34","15","75.88","177.84","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","187.00","140.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.89","59.3","","319.95","106.65","1152.07","54","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","187.00","140.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","113.14","60.5","","21.46","18.89","21.46","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","187.00","140.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","113.14","60.5","","18.03","18.03","18.03","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.12","44.45","","139.92","139.92","139.92","1 through 10","28.35","146.7","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","146.70","78.45","","139.92","139.90","139.92","21","28.35","146.7","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","188.24","188.24","188.24","83","40.45","323.95","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","341.00","255.75","TRICARE [160005]","HB NWH TRICARE","323.95","95","","49.74","47.25","49.74","1 through 10","40.45","323.95","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.57","44.45","","255.24","151.26","255.24","1 through 10","40.45","323.95","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","194.55","194.55","583.65","85","42.57","267.51","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","255.24","151.26","255.24","87","42.57","267.51","percent of total billed charges",""
"Parathyroid Spect","PX-34000130","CDM","78071","CPT","0341","RC","","","","both","","","2499.00","1874.25","MEDICARE [2001]","HB NWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1824.27","other","OPPS APC"
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0300","RC","","","","inpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.07","70.6","","45.36","45.36","45.36","1 through 10","34.16","43.07","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.46","84","5.89","57.95","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","61.00","45.75","TRICARE [160005]","HB NWH TRICARE","57.95","95","","7.24","7.24","118.00","1 through 10","5.89","57.95","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","65.63","67","6.2","47.85","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","34.57","1 through 10","6.2","47.85","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","45.36","45.36","1 through 10","6.2","47.85","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","21.48","45.36","104","6.2","47.85","percent of total billed charges",""
"Particle Agglutination Screen","PX-30000862","CDM","86403","CPT","0302","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","1 through 10","11.31","97.85","percent of total billed charges",""
"Particle Agglutination Screen","PX-30000862","CDM","86403","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","76.88","76.88","1 through 10","10.51","80.8","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","81.00","60.75","AETNA [1001]","HB CH AETNA HMO / PPO","47.22","58.3","","44.80","44.80","44.80","118","14.73","88.68","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","81.00","60.75","TRICARE [160005]","HB NWH TRICARE","76.95","95","","158.00","158.00","158.00","1 through 10","14.73","88.68","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","121.47","60.74","121.47","1 through 10","14.73","88.68","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","46.30","46.30","92.59","76","9.6","63.54","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","60.74","35.99","60.74","106","9.6","63.54","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","464.71","67.87","1012.10","221","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","293.04","293.04","293.04","11","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","983.89","983.89","983.89","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.60","58","","677.18","677.18","677.18","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.50","62.5","","46.58","46.58","46.58","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","747.15","747.15","747.15","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","1141.67","481.21","1141.67","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","76.54","76.54","76.54","1 through 10","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","273.64","94.28","1367.51","138","186.69","327.22","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","720.78","230.14","2010.94","427","210","329.49","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.06","59.3","","344.45","344.45","344.45","1 through 10","210","329.49","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","1120.13","1120.13","1120.13","1 through 10","210","329.49","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","456.17","105.33","1284.66","242","210","329.49","percent of total billed charges",""
"PATCH BIOLOGICAL 1CM 6 WMM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10126694","CDM","C1781","HCPCS","0278","RC","","","","both","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","1862.60","353.13","2619.54","16","188.02","329.56","percent of total billed charges",""
"PATCH BIOLOGICAL 1CM 6 WMM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10126694","CDM","C1781","HCPCS","0278","RC","","","","both","","","423.00","317.25","WELLPOINT [1015]","HB CH WELLPOINT","329.56","77.91","","2876.71","1548.58","2876.71","1 through 10","188.02","329.56","percent of total billed charges",""
"PATCH BIOLOGICAL 1CM 6 WMM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10126694","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","1151.69","270.51","3652.50","14","211.5","331.84","percent of total billed charges",""
"PATCH BIOLOGICAL 1CM 6 WMM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10126694","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.84","78.45","","2808.04","1107.07","2808.04","12","211.5","331.84","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","1862.60","353.13","2619.54","16","296.04","518.88","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","666.00","499.50","WELLPOINT [1015]","HB CH WELLPOINT","518.88","77.91","","2876.71","1548.58","2876.71","1 through 10","296.04","518.88","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","394.94","59.3","","1151.69","270.51","3652.50","14","333","522.48","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","2808.04","1107.07","2808.04","12","333","522.48","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","444.00","333.00","AETNA [1001]","HB CH AETNA HMO / PPO","258.85","58.3","","1862.60","353.13","2619.54","16","197.36","345.92","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","444.00","333.00","WELLPOINT [1015]","HB CH WELLPOINT","345.92","77.91","","2876.71","1548.58","2876.71","1 through 10","197.36","345.92","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","263.29","59.3","","1151.69","270.51","3652.50","14","222","348.32","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","348.32","78.45","","2808.04","1107.07","2808.04","12","222","348.32","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","AETNA [1001]","HB CH AETNA HMO / PPO","795.80","58.3","","1530.90","1160.93","1884.08","89","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","723.45","53","","5253.92","5253.92","5253.92","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","791.70","58","","12181.47","12181.47","12181.47","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","853.13","62.5","","1350.68","1350.68","1350.68","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","606.74","44.45","","1910.74","891.94","1910.74","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB CH WELLPOINT","1063.47","77.91","","1829.79","1561.50","2617.12","88","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","809.45","59.3","","1359.46","1201.30","1689.00","61","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","809.45","59.3","","1718.92","1718.92","1718.92","1 through 10","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1070.84","78.45","","1910.74","1019.06","2344.84","74","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","AETNA [1001]","HB CH AETNA HMO / PPO","795.80","58.3","","1530.90","1160.93","1884.08","89","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","723.45","53","","5253.92","5253.92","5253.92","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","791.70","58","","12181.47","12181.47","12181.47","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","853.13","62.5","","1350.68","1350.68","1350.68","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","606.74","44.45","","1910.74","891.94","1910.74","1 through 10","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB CH WELLPOINT","1063.47","77.91","","1829.79","1561.50","2617.12","88","606.74","1063.47","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","809.45","59.3","","1359.46","1201.30","1689.00","61","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","809.45","59.3","","1718.92","1718.92","1718.92","1 through 10","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1070.84","78.45","","1910.74","1019.06","2344.84","74","682.5","1070.84","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","28508.56","21381.42","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8906.50","","Case rate ($8,906.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,149.41, add-ons for qualifying new technology services are included. If operating cost exceeds $54,291.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,622.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,225.89. The transfer operating threshold is the transfer adjustment factor * $9,149.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.63. The transfer capital threshold is the transfer adjustment factor * $680.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9981.31","9981.31","9981.31","1 through 10","8728.37","10552.42","other","Inpatient Replacement Plans DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","28508.56","21381.42","MEDICARE [2001]","HB NWH MEDICARE","8906.50","","Case rate ($8,906.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,149.41, add-ons for qualifying new technology services are included. If operating cost exceeds $54,291.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,622.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,225.89. The transfer operating threshold is the transfer adjustment factor * $9,149.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.63. The transfer capital threshold is the transfer adjustment factor * $680.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10125.41","5785.65","10143.61","53","8728.37","10552.42","other","Inpatient Replacement Plans DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","28508.56","21381.42","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8728.37","","Case rate ($8,906.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,149.41, add-ons for qualifying new technology services are included. If operating cost exceeds $54,291.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,622.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,225.89. The transfer operating threshold is the transfer adjustment factor * $9,149.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.63. The transfer capital threshold is the transfer adjustment factor * $680.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9047.04","7756.67","9085.77","1 through 10","8728.37","10552.42","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","28508.56","21381.42","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8728.37","","Case rate ($8,906.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,149.41, add-ons for qualifying new technology services are included. If operating cost exceeds $54,291.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,622.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,225.89. The transfer operating threshold is the transfer adjustment factor * $9,149.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.63. The transfer capital threshold is the transfer adjustment factor * $680.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9065.54","9065.54","9082.54","1 through 10","8728.37","10552.42","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","38554.07","28915.55","FALLON HEALTH [1008]","HB NWH MEDICARE","16828.03","","Case rate ($16,828.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,722.21, add-ons for qualifying new technology services are included. If operating cost exceeds $60,864.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,658.46. The transfer operating threshold is the transfer adjustment factor * $15,722.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.58. The transfer capital threshold is the transfer adjustment factor * $1,169.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16222.43","16222.43","16222.43","1 through 10","14998.72","18133.12","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","38554.07","28915.55","MEDICARE [2001]","HB NWH MEDICARE","16828.03","","Case rate ($16,828.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,722.21, add-ons for qualifying new technology services are included. If operating cost exceeds $60,864.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,658.46. The transfer operating threshold is the transfer adjustment factor * $15,722.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.58. The transfer capital threshold is the transfer adjustment factor * $1,169.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17800.84","10287.76","17832.84","39","14998.72","18133.12","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","38554.07","28915.55","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14998.72","","Case rate ($15,304.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,722.21, add-ons for qualifying new technology services are included. If operating cost exceeds $60,864.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,135.25. The transfer operating threshold is the transfer adjustment factor * $15,722.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.58. The transfer capital threshold is the transfer adjustment factor * $1,169.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12265.95","12265.95","15906.80","1 through 10","14998.72","18133.12","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","38554.07","28915.55","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14998.72","","Case rate ($15,304.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,722.21, add-ons for qualifying new technology services are included. If operating cost exceeds $60,864.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,135.25. The transfer operating threshold is the transfer adjustment factor * $15,722.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.58. The transfer capital threshold is the transfer adjustment factor * $1,169.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15899.99","15899.99","15899.99","1 through 10","14998.72","18133.12","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","38554.07","28915.55","WELLSENSE NH [1050]","HB NWH MEDICARE","16828.03","","Case rate ($16,828.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,722.21, add-ons for qualifying new technology services are included. If operating cost exceeds $60,864.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,658.46. The transfer operating threshold is the transfer adjustment factor * $15,722.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.58. The transfer capital threshold is the transfer adjustment factor * $1,169.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15939.30","15939.30","15939.30","1 through 10","14998.72","18133.12","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","21612.09","16209.07","MEDICARE [2001]","HB NWH MEDICARE","7188.48","","Case rate ($7,188.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,716.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,858.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,688.86. The transfer operating threshold is the transfer adjustment factor * $6,716.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.61. The transfer capital threshold is the transfer adjustment factor * $499.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7212.54","7212.44","7225.50","14","6407.05","7745.97","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","21612.09","16209.07","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6407.05","","Case rate ($6,537.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,716.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,858.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,038.19. The transfer operating threshold is the transfer adjustment factor * $6,716.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.61. The transfer capital threshold is the transfer adjustment factor * $499.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6449.49","6449.49","6449.49","1 through 10","6407.05","7745.97","other","Inpatient DRG"
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3407.01","2555.26","AETNA [1001]","HB CH AETNA HMO / PPO","1986.29","58.3","","3969.00","3969.00","3969.00","1 through 10","1805.72","2654.4","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3407.01","2555.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","2020.36","59.3","","2051.00","2051.00","2051.00","1 through 10","1514.42","2672.8","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3407.01","2555.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2672.80","78.45","","1813.99","1594.60","2690.80","1 through 10","1514.42","2672.8","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","453.55","340.16","AETNA [1001]","HB CH AETNA HMO / PPO","264.42","58.3","","257.16","257.16","257.16","23","201.6","998.43","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","453.55","340.16","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","327.01","72.1","","453.55","341.98","453.55","1 through 10","201.6","998.43","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","453.55","340.16","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","287.55","63.4","","300.70","293.61","300.70","12","201.6","998.43","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","453.55","340.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","331.09","73","","257.16","257.16","257.16","1 through 10","201.6","998.43","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","453.55","340.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.60","44.45","","640.79","640.79","640.79","1 through 10","201.6","998.43","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","453.55","340.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.75","52.2","","233.58","233.58","233.58","35","226.78","607.65","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","453.55","340.16","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","261.70","57.7","","273.49","273.49","273.49","56","226.78","607.65","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","453.55","340.16","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","274.40","60.5","","287.10","287.10","341.98","1 through 10","226.78","607.65","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","453.55","340.16","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","274.40","60.5","","276.21","276.21","276.21","1 through 10","226.78","607.65","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","453.55","340.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","355.81","78.45","","589.65","453.55","640.79","36","226.78","607.65","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","AETNA [1001]","HB CH AETNA HMO / PPO","514.21","58.3","","1530.90","1160.93","1884.08","89","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","467.46","53","","5253.92","5253.92","5253.92","1 through 10","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","511.56","58","","12181.47","12181.47","12181.47","1 through 10","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","551.25","62.5","","1350.68","1350.68","1350.68","1 through 10","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.05","44.45","","1910.74","891.94","1910.74","1 through 10","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","WELLPOINT [1015]","HB CH WELLPOINT","687.17","77.91","","1829.79","1561.50","2617.12","88","392.05","687.17","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.03","59.3","","1359.46","1201.30","1689.00","61","441","691.93","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.03","59.3","","1718.92","1718.92","1718.92","1 through 10","441","691.93","percent of total billed charges",""
"PEG 31X8MM BUTTON PATELLA KNEE VANGUARD UHMWPE 3 SERIES A STANDARD","SUP-ITM-10016631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.93","78.45","","1910.74","1019.06","2344.84","74","441","691.93","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1530.90","1160.93","1884.08","89","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1203.63","53","","5253.92","5253.92","5253.92","1 through 10","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1317.18","58","","12181.47","12181.47","12181.47","1 through 10","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1419.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.46","44.45","","1910.74","891.94","1910.74","1 through 10","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","1829.79","1561.50","2617.12","88","1009.46","1769.34","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1359.46","1201.30","1689.00","61","1135.5","1781.6","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1135.5","1781.6","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","1910.74","1019.06","2344.84","74","1135.5","1781.6","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","AETNA [1001]","HB CH AETNA HMO / PPO","188.89","58.3","","464.71","67.87","1012.10","221","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","188.89","58.3","","293.04","293.04","293.04","11","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","171.72","53","","983.89","983.89","983.89","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","187.92","58","","677.18","677.18","677.18","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","202.50","62.5","","46.58","46.58","46.58","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","236.52","73","","747.15","747.15","747.15","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.02","44.45","","1141.67","481.21","1141.67","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.02","44.45","","76.54","76.54","76.54","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","WELLPOINT [1015]","HB CH WELLPOINT","252.43","77.91","","273.64","94.28","1367.51","138","144.02","252.43","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","192.13","59.3","","720.78","230.14","2010.94","427","162","254.18","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","192.13","59.3","","344.45","344.45","344.45","1 through 10","162","254.18","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","254.18","78.45","","1120.13","1120.13","1120.13","1 through 10","162","254.18","percent of total billed charges",""
"PEG BONE 14X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.18","78.45","","456.17","105.33","1284.66","242","162","254.18","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","464.71","67.87","1012.10","221","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","293.04","293.04","293.04","11","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","983.89","983.89","983.89","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.63","58","","677.18","677.18","677.18","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.31","62.5","","46.58","46.58","46.58","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","747.15","747.15","747.15","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","1141.67","481.21","1141.67","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","76.54","76.54","76.54","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","273.64","94.28","1367.51","138","105.48","184.88","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","720.78","230.14","2010.94","427","118.65","186.16","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.72","59.3","","344.45","344.45","344.45","1 through 10","118.65","186.16","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","1120.13","1120.13","1120.13","1 through 10","118.65","186.16","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","456.17","105.33","1284.66","242","118.65","186.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","464.71","67.87","1012.10","221","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","293.04","293.04","293.04","11","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","983.89","983.89","983.89","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","182.70","58","","677.18","677.18","677.18","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","196.88","62.5","","46.58","46.58","46.58","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","747.15","747.15","747.15","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","1141.67","481.21","1141.67","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","76.54","76.54","76.54","1 through 10","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","273.64","94.28","1367.51","138","140.02","245.42","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","720.78","230.14","2010.94","427","157.5","247.12","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","186.80","59.3","","344.45","344.45","344.45","1 through 10","157.5","247.12","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","1120.13","1120.13","1120.13","1 through 10","157.5","247.12","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","456.17","105.33","1284.66","242","157.5","247.12","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","AETNA [1001]","HB CH AETNA HMO / PPO","188.89","58.3","","464.71","67.87","1012.10","221","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","188.89","58.3","","293.04","293.04","293.04","11","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","171.72","53","","983.89","983.89","983.89","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","187.92","58","","677.18","677.18","677.18","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","202.50","62.5","","46.58","46.58","46.58","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","236.52","73","","747.15","747.15","747.15","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.02","44.45","","1141.67","481.21","1141.67","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.02","44.45","","76.54","76.54","76.54","1 through 10","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.00","243.00","WELLPOINT [1015]","HB CH WELLPOINT","252.43","77.91","","273.64","94.28","1367.51","138","144.02","252.43","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","192.13","59.3","","720.78","230.14","2010.94","427","162","254.18","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","192.13","59.3","","344.45","344.45","344.45","1 through 10","162","254.18","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","254.18","78.45","","1120.13","1120.13","1120.13","1 through 10","162","254.18","percent of total billed charges",""
"PEG BONE 16X2.0MM LOCKING SMOOTH GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.00","243.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.18","78.45","","456.17","105.33","1284.66","242","162","254.18","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","464.71","67.87","1012.10","221","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","293.04","293.04","293.04","11","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","983.89","983.89","983.89","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","200.10","58","","677.18","677.18","677.18","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","215.63","62.5","","46.58","46.58","46.58","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","747.15","747.15","747.15","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","1141.67","481.21","1141.67","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","76.54","76.54","76.54","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","273.64","94.28","1367.51","138","153.35","268.79","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","720.78","230.14","2010.94","427","172.5","270.65","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","204.59","59.3","","344.45","344.45","344.45","1 through 10","172.5","270.65","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","1120.13","1120.13","1120.13","1 through 10","172.5","270.65","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","456.17","105.33","1284.66","242","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","464.71","67.87","1012.10","221","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","293.04","293.04","293.04","11","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","983.89","983.89","983.89","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","200.10","58","","677.18","677.18","677.18","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","215.63","62.5","","46.58","46.58","46.58","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","747.15","747.15","747.15","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","1141.67","481.21","1141.67","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","76.54","76.54","76.54","1 through 10","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","273.64","94.28","1367.51","138","153.35","268.79","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","720.78","230.14","2010.94","427","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","204.59","59.3","","344.45","344.45","344.45","1 through 10","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","1120.13","1120.13","1120.13","1 through 10","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","456.17","105.33","1284.66","242","172.5","270.65","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","464.71","67.87","1012.10","221","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","293.04","293.04","293.04","11","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","983.89","983.89","983.89","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","180.96","58","","677.18","677.18","677.18","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","195.00","62.5","","46.58","46.58","46.58","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","747.15","747.15","747.15","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","1141.67","481.21","1141.67","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","76.54","76.54","76.54","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","273.64","94.28","1367.51","138","138.68","243.08","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","720.78","230.14","2010.94","427","156","244.76","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","185.02","59.3","","344.45","344.45","344.45","1 through 10","156","244.76","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","1120.13","1120.13","1120.13","1 through 10","156","244.76","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","456.17","105.33","1284.66","242","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","464.71","67.87","1012.10","221","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","293.04","293.04","293.04","11","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","983.89","983.89","983.89","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","180.96","58","","677.18","677.18","677.18","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","195.00","62.5","","46.58","46.58","46.58","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","747.15","747.15","747.15","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","1141.67","481.21","1141.67","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","76.54","76.54","76.54","1 through 10","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","273.64","94.28","1367.51","138","138.68","243.08","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","720.78","230.14","2010.94","427","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","185.02","59.3","","344.45","344.45","344.45","1 through 10","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","1120.13","1120.13","1120.13","1 through 10","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","456.17","105.33","1284.66","242","156","244.76","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","464.71","67.87","1012.10","221","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","293.04","293.04","293.04","11","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","983.89","983.89","983.89","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.63","58","","677.18","677.18","677.18","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.31","62.5","","46.58","46.58","46.58","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","747.15","747.15","747.15","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","1141.67","481.21","1141.67","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","76.54","76.54","76.54","1 through 10","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","273.64","94.28","1367.51","138","105.48","184.88","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","720.78","230.14","2010.94","427","118.65","186.16","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.72","59.3","","344.45","344.45","344.45","1 through 10","118.65","186.16","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","1120.13","1120.13","1120.13","1 through 10","118.65","186.16","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","456.17","105.33","1284.66","242","118.65","186.16","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","AETNA [1001]","HB CH AETNA HMO / PPO","1576.64","58.3","","464.71","67.87","1012.10","221","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1576.64","58.3","","293.04","293.04","293.04","11","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1433.31","53","","983.89","983.89","983.89","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1568.52","58","","677.18","677.18","677.18","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1690.22","62.5","","46.58","46.58","46.58","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1974.18","73","","747.15","747.15","747.15","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.08","44.45","","1141.67","481.21","1141.67","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.08","44.45","","76.54","76.54","76.54","1 through 10","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.35","2028.26","WELLPOINT [1015]","HB CH WELLPOINT","2106.96","77.91","","273.64","94.28","1367.51","138","1202.08","2106.96","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.35","2028.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","1603.68","59.3","","720.78","230.14","2010.94","427","1352.18","2121.56","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.35","2028.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1603.68","59.3","","344.45","344.45","344.45","1 through 10","1352.18","2121.56","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.35","2028.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2121.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1352.18","2121.56","percent of total billed charges",""
"PELVIC PLATE 3.5/ 4.5MM 90.5 6 HOLE MATTA SS STRAIGHT","SUP-ITM-10142519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.35","2028.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2121.56","78.45","","456.17","105.33","1284.66","242","1352.18","2121.56","percent of total billed charges",""
"Peptic Ulcer And Gastritis,EXTREME","241","DRG","","","","","","","","inpatient","","","61443.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","54937.99","","Standard inlier is a Case rate ($54,937.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $64,114, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,798.22) for the length of stay and the standard reimbursement.","52440.80","52440.80","52440.80","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,EXTREME","241","DRG","","","","","","","","inpatient","","","61443.85","","MASSHEALTH [3001]","HB NWH MEDICAID","24616.84","","Case rate ($26,520.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $68,950.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,329.54 and the sum of the standard inlier and any outlier amount.","26588.97","26588.97","26588.97","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26258.02","","Fee schedule rate ($26,258.02). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,037.64) multiplied by length of stay and the outlier percent (100%).","25064.81","25064.81","25064.81","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28206.35","","Fee schedule rate ($28,206.35). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,263.64) multiplied by length of stay and the outlier percent (100%).","28206.34","26927.22","28206.34","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10023.0918","","Fee schedule rate ($24,429.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10023.0918","24429.46","24429.46","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10524.1951","","Fee schedule rate ($25,650.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10524.1951","25650.80","25650.80","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","MASSHEALTH [3001]","HB NWH MEDICAID","10793.07","","Case rate ($11,627.83). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,057.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11657.73","11657.73","11657.73","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","30237.47","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","26660.45","","Fee schedule rate ($26,660.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26660.45","26660.45","26660.45","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","16530.29","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10023.0918","","Fee schedule rate ($10,023.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10023.0918","10023.10","10023.10","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","16530.29","","MASSHEALTH [3001]","HB NWH MEDICAID","5026.41","","Case rate ($5,415.16). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,845.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5429.09","5429.09","5429.09","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","21508.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18013.62","","Standard inlier is a Case rate ($18,013.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,128, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,557.10) for the length of stay and the standard reimbursement.","18013.62","18013.62","18013.62","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","21508.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19350.22","","Standard inlier is a Case rate ($19,350.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,128, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,746.68) for the length of stay and the standard reimbursement.","19350.22","18470.66","19350.22","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","21508.54","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10023.0918","","Fee schedule rate ($14,826.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10023.0918","14255.22","14255.22","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","21508.54","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19304.57","","Fee schedule rate ($19,304.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19304.57","19304.57","19304.57","1 through 10","5026.41","96825.51","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","21508.54","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6610.87","","Case rate ($7,122.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,552.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7140.49","7140.49","7140.49","1 through 10","5026.41","96825.51","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","91004.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","68539.50","","Standard inlier is a Case rate ($68,539.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $77,104, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,728.89) for the length of stay and the standard reimbursement.","68539.50","68539.50","68539.50","1 through 10","15512.19","131636.13","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","82716.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","52011.02","","Standard inlier is a Case rate ($52,011.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,383.17) for the length of stay and the standard reimbursement.","20293.51","20293.51","20293.51","1 through 10","15512.19","131636.13","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","111636.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","72326.33","","Standard inlier is a Case rate ($72,326.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $80,720, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,266.42) for the length of stay and the standard reimbursement.","24171.98","24171.98","24171.98","1 through 10","16859.04","156736.26","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MINOR","175","DRG","","","","","","","","inpatient","","","78057.19","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","32917.85","","Fee schedule rate ($32,917.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32917.85","32917.85","32917.85","1 through 10","16859.04","156736.26","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","80488.16","60366.12","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14969.01","","Case rate ($15,274.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,691.06, add-ons for qualifying new technology services are included. If operating cost exceeds $60,833.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,109.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,107.24. The transfer operating threshold is the transfer adjustment factor * $15,691.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,167.26. The transfer capital threshold is the transfer adjustment factor * $1,167.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15443.50","15443.50","15443.50","1 through 10","14969.01","17891.1788","other","Inpatient DRG"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","337.67","50.1","","248.00","248.00","248.00","1 through 10","289.15","1873.9","percent of total billed charges",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MAJOR","030","DRG","","","","","","","","inpatient","","","54090.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","82365.50","","Fee schedule rate ($82,365.50). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($9,528.39) multiplied by length of stay and the outlier percent (100%).","9528.39","9528.39","9528.39","1 through 10","36158.17","88476.97","case rate",""
"Percutaneous Tenotomy Shoulder","PX-36000461","CDM","23929","CPT","0361","RC","","","","outpatient","","","4645.00","3483.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2327.15","50.1","","186.10","186.10","186.10","1 through 10","567.68","3644","percent of total billed charges",""
"Percutaneous Tenotomy Shoulder","PX-36000461","CDM","23929","CPT","0361","RC","","","","outpatient","","","4645.00","3483.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2754.49","59.3","","9413.40","9413.40","9413.40","1 through 10","567.68","3644","percent of total billed charges",""
"Percutaneous Tenotomy Shoulder","PX-36000461","CDM","23929","CPT","0361","RC","","","","outpatient","","","4645.00","3483.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2680.17","57.7","","2473.00","2473.00","2473.00","1 through 10","567.68","3644","percent of total billed charges",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","23385.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22589.31","","Standard inlier is a Case rate ($22,589.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $33,221, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,206.46) for the length of stay and the standard reimbursement.","22589.30","22589.30","22589.30","1 through 10","2424","41385.17","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","23385.09","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11736.9252","","Fee schedule rate ($25,082.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11736.9252","25082.16","25082.16","1 through 10","2424","41385.17","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","19185.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15206.65","","Standard inlier is a Case rate ($15,206.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,248, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,158.64) for the length of stay and the standard reimbursement.","15206.65","15206.65","15206.65","1 through 10","2424","41385.17","case rate",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26309.12","19731.84","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9248.74","","Case rate ($9,248.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,500.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,643.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,648.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,541.96. The transfer operating threshold is the transfer adjustment factor * $9,500.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.78. The transfer capital threshold is the transfer adjustment factor * $706.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5958.46","5958.46","5958.46","1 through 10","9063.77","10957.89","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26309.12","19731.84","MEDICARE [2001]","HB NWH MEDICARE","9248.74","","Case rate ($9,248.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,500.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,643.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,648.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,541.96. The transfer operating threshold is the transfer adjustment factor * $9,500.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.78. The transfer capital threshold is the transfer adjustment factor * $706.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10217.99","9887.96","10236.36","19","9063.77","10957.89","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26309.12","19731.84","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9063.77","","Case rate ($9,248.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,500.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,643.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,648.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,541.96. The transfer operating threshold is the transfer adjustment factor * $9,500.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.78. The transfer capital threshold is the transfer adjustment factor * $706.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8834.97","8834.97","9125.59","1 through 10","9063.77","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26309.12","19731.84","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","9063.77","","Case rate ($9,248.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,500.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,643.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,648.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,541.96. The transfer operating threshold is the transfer adjustment factor * $9,500.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.78. The transfer capital threshold is the transfer adjustment factor * $706.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10437.32","10437.32","10437.32","1 through 10","9063.77","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26309.12","19731.84","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9063.77","","Case rate ($9,248.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,500.97, add-ons for qualifying new technology services are included. If operating cost exceeds $54,643.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,648.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,541.96. The transfer operating threshold is the transfer adjustment factor * $9,500.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.78. The transfer capital threshold is the transfer adjustment factor * $706.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9165.99","9165.99","9165.99","1 through 10","9063.77","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","26357.30","19767.97","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14569.96","","Case rate ($14,145.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,531.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,673.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,064.60. The transfer operating threshold is the transfer adjustment factor * $14,531.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.99. The transfer capital threshold is the transfer adjustment factor * $1,080.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7246.87","7246.87","7246.87","1 through 10","13862.68","16759.67","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","26357.30","19767.97","HUMANA [1012]","HB NWH MEDICARE","15553.43","","Case rate ($15,553.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,531.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,673.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,472.44. The transfer operating threshold is the transfer adjustment factor * $14,531.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.99. The transfer capital threshold is the transfer adjustment factor * $1,080.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13788.30","13788.30","13788.30","1 through 10","13862.68","16759.67","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","26357.30","19767.97","MEDICARE [2001]","HB NWH MEDICARE","15553.43","","Case rate ($15,553.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,531.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,673.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,472.44. The transfer operating threshold is the transfer adjustment factor * $14,531.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.99. The transfer capital threshold is the transfer adjustment factor * $1,080.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15438.65","7733.20","15466.40","22","13862.68","16759.67","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","26357.30","19767.97","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13862.68","","Case rate ($14,145.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,531.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,673.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,022.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,064.60. The transfer operating threshold is the transfer adjustment factor * $14,531.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.99. The transfer capital threshold is the transfer adjustment factor * $1,080.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13796.48","13796.48","13796.48","1 through 10","13862.68","16759.67","other","Inpatient DRG"
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","39647.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24416.88","","Standard inlier is a Case rate ($24,416.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,465.87) for the length of stay and the standard reimbursement.","24007.89","24007.89","24007.89","1 through 10","5565.61","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","39647.05","","MASSHEALTH [3001]","HB NWH MEDICAID","10539.47","","Case rate ($11,354.61). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,784.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11383.81","11383.81","11383.81","1 through 10","5565.61","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MINOR","048","DRG","","","","","","","","inpatient","","","34815.72","","MASSHEALTH [3001]","HB NWH MEDICAID","5565.61","","Case rate ($5,996.06). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,426.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5347.65","5347.65","5347.65","1 through 10","5565.61","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","20059.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17991.39","","Standard inlier is a Case rate ($17,991.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,553.80) for the length of stay and the standard reimbursement.","17991.38","17991.38","17991.38","1 through 10","5565.61","37657.77","case rate",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","67843.44","50882.58","MEDICARE [2001]","HB NWH MEDICARE","20945.27","","Case rate ($20,945.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,568.88, add-ons for qualifying new technology services are included. If operating cost exceeds $64,711.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,397.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,489.53. The transfer operating threshold is the transfer adjustment factor * $19,568.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.73. The transfer capital threshold is the transfer adjustment factor * $1,455.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21591.39","21591.39","21591.39","1 through 10","18668.39","22331.3398","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","67843.44","50882.58","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","18668.39","","Case rate ($19,049.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,568.88, add-ons for qualifying new technology services are included. If operating cost exceeds $64,711.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,397.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,593.64. The transfer operating threshold is the transfer adjustment factor * $19,568.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,455.73. The transfer capital threshold is the transfer adjustment factor * $1,455.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19254.74","19254.74","19254.74","1 through 10","18668.39","22331.3398","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","24689.41","18517.06","MEDICARE [2001]","HB NWH MEDICARE","36782.58","","Case rate ($36,782.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $34,365.47, add-ons for qualifying new technology services are included. If operating cost exceeds $79,507.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,498.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,226.12. The transfer operating threshold is the transfer adjustment factor * $34,365.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,556.46. The transfer capital threshold is the transfer adjustment factor * $2,556.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","36001.55","36001.55","36001.55","1 through 10","32784.1","37302.2969","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","49469.87","37102.40","MEDICARE [2001]","HB NWH MEDICARE","18269.62","","Case rate ($18,269.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,767.86, add-ons for qualifying new technology services are included. If operating cost exceeds $63,910.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,338.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,873.48. The transfer operating threshold is the transfer adjustment factor * $18,767.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,396.15. The transfer capital threshold is the transfer adjustment factor * $1,396.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20159.88","14959.46","20196.38","1 through 10","17904.23","20888.5347","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","49469.87","37102.40","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","17904.23","","Case rate ($18,269.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,767.86, add-ons for qualifying new technology services are included. If operating cost exceeds $63,910.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,338.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,873.48. The transfer operating threshold is the transfer adjustment factor * $18,767.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,396.15. The transfer capital threshold is the transfer adjustment factor * $1,396.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18004.83","18004.83","18004.83","1 through 10","17904.23","20888.5347","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","61899.07","46424.30","MEDICARE [2001]","HB NWH MEDICARE","34017.11","","Case rate ($34,017.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,781.74, add-ons for qualifying new technology services are included. If operating cost exceeds $76,924.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,306.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $31,652.87. The transfer operating threshold is the transfer adjustment factor * $31,781.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,364.25. The transfer capital threshold is the transfer adjustment factor * $2,364.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34644.52","34644.52","34644.52","1 through 10","30319.25","35831.8026","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","61899.07","46424.30","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","30319.25","","Case rate ($30,938.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,781.74, add-ons for qualifying new technology services are included. If operating cost exceeds $76,924.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,306.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $28,573.76. The transfer operating threshold is the transfer adjustment factor * $31,781.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,364.25. The transfer capital threshold is the transfer adjustment factor * $2,364.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10649.35","10649.35","10649.35","1 through 10","30319.25","35831.8026","other","Inpatient DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","32764.70","24573.52","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","13299.13","","Case rate ($13,299.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,661.81, add-ons for qualifying new technology services are included. If operating cost exceeds $58,804.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,958.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $12,282.82. The transfer operating threshold is the transfer adjustment factor * $13,661.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,016.31. The transfer capital threshold is the transfer adjustment factor * $1,016.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13085.07","13085.07","13085.07","1 through 10","13033.15","15180.6039","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","32764.70","24573.52","MEDICARE [2001]","HB NWH MEDICARE","13299.13","","Case rate ($13,299.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,661.81, add-ons for qualifying new technology services are included. If operating cost exceeds $58,804.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,958.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $12,282.82. The transfer operating threshold is the transfer adjustment factor * $13,661.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,016.31. The transfer capital threshold is the transfer adjustment factor * $1,016.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14651.24","14651.24","14651.24","1 through 10","13033.15","15180.6039","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis,EXTREME","224","DRG","","","","","","","","inpatient","","","78674.81","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","41013.83","","Fee schedule rate ($41,013.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41013.52","41013.52","41013.52","1 through 10","11843.295","163254.6","case rate",""
"Peritoneal Adhesiolysis,MAJOR","224","DRG","","","","","","","","inpatient","","","79393.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","52832.28","","Standard inlier is a Case rate ($52,832.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $65,848, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,499.75) for the length of stay and the standard reimbursement.","50431.49","50431.49","50431.49","1 through 10","11843.295","163254.6","case rate",""
"Peritoneal Adhesiolysis,MAJOR","224","DRG","","","","","","","","inpatient","","","79393.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","56752.40","","Standard inlier is a Case rate ($56,752.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $65,848, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,055.76) for the length of stay and the standard reimbursement.","6566.58","6566.58","6566.58","1 through 10","11843.295","163254.6","case rate",""
"Peritoneal Adhesiolysis,MAJOR","224","DRG","","","","","","","","inpatient","","","79393.17","","MASSHEALTH [3001]","HB NWH MEDICAID","18548.60","","Case rate ($19,983.18). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,413.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20034.57","20034.57","20034.57","1 through 10","11843.295","163254.6","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","46400.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39940.78","","Standard inlier is a Case rate ($39,940.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,791, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,669.42) for the length of stay and the standard reimbursement.","39940.77","39940.77","39940.77","1 through 10","11843.295","163254.6","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","46400.55","","MASSHEALTH [3001]","HB NWH MEDICAID","14292.14","","Case rate ($15,397.53). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,827.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19296.41","19296.41","19296.41","1 through 10","11843.295","163254.6","case rate",""
"Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock,MAJOR","170","DRG","","","","","","","","inpatient","","","106343.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","58731.5268","","Fee schedule rate ($79,840.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58731.5268","79840.80","79840.80","1 through 10","16469.49","131736.09","case rate",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","48240.52","36180.39","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","19015.82","","Case rate ($18,461.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,107.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,352.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,051.12. The transfer operating threshold is the transfer adjustment factor * $18,965.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.84. The transfer capital threshold is the transfer adjustment factor * $1,410.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","20178.63","20178.63","20178.63","1 through 10","18092.72","21873.69","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","48240.52","36180.39","MEDICARE [2001]","HB NWH MEDICARE","20299.39","","Case rate ($20,299.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,107.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,352.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $18,888.54. The transfer operating threshold is the transfer adjustment factor * $18,965.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.84. The transfer capital threshold is the transfer adjustment factor * $1,410.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21501.10","21500.83","21539.77","1 through 10","18092.72","21873.69","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","48240.52","36180.39","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","18092.72","","Case rate ($18,461.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,107.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,352.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,051.12. The transfer operating threshold is the transfer adjustment factor * $18,965.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.84. The transfer capital threshold is the transfer adjustment factor * $1,410.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19218.69","19218.69","19236.21","1 through 10","18092.72","21873.69","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","48240.52","36180.39","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","18092.72","","Case rate ($18,461.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,965.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,107.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,352.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,051.12. The transfer operating threshold is the transfer adjustment factor * $18,965.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.84. The transfer capital threshold is the transfer adjustment factor * $1,410.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","194.91","194.91","194.91","1 through 10","18092.72","21873.69","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","84450.79","63338.09","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","28492.06","","Case rate ($27,662.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,416.58, add-ons for qualifying new technology services are included. If operating cost exceeds $73,558.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,055.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $25,548.27. The transfer operating threshold is the transfer adjustment factor * $28,416.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,113.92. The transfer capital threshold is the transfer adjustment factor * $2,113.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","30386.51","30386.51","30386.51","1 through 10","27108.95","32774.09","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","84450.79","63338.09","MEDICARE [2001]","HB NWH MEDICARE","30415.27","","Case rate ($30,415.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,416.58, add-ons for qualifying new technology services are included. If operating cost exceeds $73,558.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,055.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $28,301.34. The transfer operating threshold is the transfer adjustment factor * $28,416.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,113.92. The transfer capital threshold is the transfer adjustment factor * $2,113.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","32373.83","32373.41","32432.03","11","27108.95","32774.09","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","84450.79","63338.09","MOLINA [1014]","HB NWH MEDICARE","30415.27","","Case rate ($30,415.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,416.58, add-ons for qualifying new technology services are included. If operating cost exceeds $73,558.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,055.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $28,301.34. The transfer operating threshold is the transfer adjustment factor * $28,416.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,113.92. The transfer capital threshold is the transfer adjustment factor * $2,113.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","58449.92","58449.92","58449.92","1 through 10","27108.95","32774.09","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","62416.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47461.77","","Standard inlier is a Case rate ($47,461.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,974, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,737.00) for the length of stay and the standard reimbursement.","47461.76","47461.76","47461.76","1 through 10","16469.49","104296.44","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","62416.94","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","38562.2286","","Fee schedule rate ($46,490.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38562.2286","63210.56","63210.56","1 through 10","16469.49","104296.44","case rate",""
"Permanent Cardiac Pacemaker Implant Without Cc/McC","244","MS-DRG","","","","","","","","inpatient","","","47752.83","35814.62","MEDICARE [2001]","HB NWH MEDICARE","15660.03","","Case rate ($15,660.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,087.12, add-ons for qualifying new technology services are included. If operating cost exceeds $61,229.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,138.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $14,463.32. The transfer operating threshold is the transfer adjustment factor * $16,087.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.72. The transfer capital threshold is the transfer adjustment factor * $1,196.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17255.33","17255.33","17255.33","1 through 10","15346.83","17846.6783","other","Inpatient Replacement Plans DRG"
"Perq Device Breast 1st Imag","PX-76001936","CDM","19281","CPT","0761","RC","","","","both","","","808.00","606.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.22","1887.22","1887.22","1 through 10","359.16","2253.63","other","OPPS APC"
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","823.22","818.85","826.35","1 through 10","236.91","2253.63","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","480.00","360.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","599.38","599.38","599.38","1 through 10","213.36","775.26","other","Multiple Surgery"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","480.00","360.00","MEDICARE [2001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","12","213.36","775.26","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","480.00","360.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.83","288.83","288.83","1 through 10","213.36","775.26","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","outpatient","","","480.00","360.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","374.20","374.20","374.20","1 through 10","231.42","1873.9","other","ASC "
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","571.61","571.61","571.61","1 through 10","231.42","1873.9","other","Multiple Surgery"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","599.38","599.38","599.38","1 through 10","87.57","775.26","other","Multiple Surgery"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","MEDICARE [2001]","HB NWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","12","87.57","775.26","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.83","288.83","288.83","1 through 10","87.57","775.26","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","outpatient","","","197.00","147.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","571.61","571.61","571.61","1 through 10","93.55","1873.9","other","Multiple Surgery"
"Perq Sft Tiss Loc Device Plmt 1st Les W/Gdnce","PX-76002177","CDM","10035","CPT","0761","RC","","","","both","","","436.00","327.00","AETNA [1001]","HB CH AETNA HMO / PPO","254.19","58.3","","480.82","480.82","480.82","1 through 10","231.08","860.54","percent of total billed charges",""
"Perq Sft Tiss Loc Device Plmt Add Les W/Gdnce","PX-76002178","CDM","10036","CPT","0761","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","110.5","173.37","percent of total billed charges",""
"Perq Sft Tiss Loc Device Plmt Add Les W/Gdnce","PX-76002178","CDM","10036","CPT","0761","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","96.54","96.54","96.54","1 through 10","72.92","98.23","percent of total billed charges",""
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","both","","","14222.00","10666.50","MEDICARE [2001]","HB NWH MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8483.61","8483.61","15280.12","1 through 10","5129.63","11080.36","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","both","","","14222.00","10666.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","5934.00","5934.00","5934.00","1 through 10","5129.63","11080.36","per diem",""
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","both","","","14222.00","10666.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8315.94","8315.94","8315.94","1 through 10","5129.63","11080.36","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","outpatient","","","14222.00","10666.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","9216.18","9216.18","9216.18","1 through 10","5129.63","14681.05","other","ASC "
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","outpatient","","","14222.00","10666.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","5129.63","","Case rate ($5,129.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","12054.63","12054.63","12054.63","1 through 10","5129.63","14681.05","other","Multiple Surgery"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","15272.00","11454.00","MEDICARE [2001]","HB NWH MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8483.61","8483.61","8483.61","1 through 10","5129.63","11898.42","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","15272.00","11454.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","24944.82","24944.82","24944.82","1 through 10","5129.63","11898.42","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","outpatient","","","15272.00","11454.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","9216.18","9216.18","9216.18","1 through 10","5129.63","14681.05","other","ASC "
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","7610.00","5707.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3775.72","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3778.11","3778.11","3778.11","1 through 10","2361.01","5928.95","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1680.16","1704.45","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","FALLON HEALTH [1008]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1678.33","1678.33","1678.33","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","HUMANA [1012]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1699.57","1697.52","1699.57","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","MEDICARE [2001]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","114","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1700.32","1673.33","1702.52","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","5620.00","4215.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1700.52","1673.84","1700.52","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","outpatient","","","5620.00","4215.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3332.66","59.3","","3202.49","3202.49","3202.49","1 through 10","2810","4408.89","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","outpatient","","","5620.00","4215.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4408.89","78.45","","4201.49","4201.49","4201.49","1 through 10","2810","4408.89","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1704.45","1704.45","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","5753.00","4314.75","MEDICARE [2001]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1707.48","1732.16","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","5753.00","4314.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1674.83","1674.83","1699.02","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","5753.00","4314.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1697.52","1697.52","1697.52","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","5753.00","4314.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3411.53","59.3","","3035.03","3035.03","3035.03","1 through 10","2557.21","4513.23","percent of total billed charges",""
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","5753.00","4314.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1704.45","1697.52","1714.84","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","outpatient","","","5753.00","4314.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3411.53","59.3","","3278.08","3278.08","3278.08","1 through 10","2876.5","4513.23","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","5724.00","4293.00","AETNA [1001]","HB CH AETNA HMO / PPO","3337.09","58.3","","3155.92","3155.92","3155.92","1 through 10","1645.55","5172.03","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","5724.00","4293.00","HUMANA [1012]","HB NWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1711.37","1711.37","1711.37","1 through 10","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","5724.00","4293.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1697.92","1697.52","1702.52","31","1645.55","5172.03","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","5724.00","4293.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3394.33","59.3","","3261.68","3183.75","3261.68","1 through 10","2862","4490.48","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","5724.00","4293.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4490.48","78.45","","3452.61","3452.61","7057.11","1 through 10","2862","4490.48","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","197.17","197.17","264.79","1 through 10","280.04","598.5","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","309.14","49.07","","28.28","28.28","28.88","1 through 10","122.71","494.24","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","315.63","50.1","","28.92","28.32","28.92","1 through 10","122.71","494.24","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","AETNA [1001]","HB CH AETNA HMO / PPO","660.07","58.3","","464.71","67.87","1012.10","221","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","660.07","58.3","","293.04","293.04","293.04","11","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","600.07","53","","983.89","983.89","983.89","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","656.68","58","","677.18","677.18","677.18","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","707.63","62.5","","46.58","46.58","46.58","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","747.15","747.15","747.15","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","1141.67","481.21","1141.67","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","76.54","76.54","76.54","1 through 10","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","WELLPOINT [1015]","HB CH WELLPOINT","882.10","77.91","","273.64","94.28","1367.51","138","503.26","882.1","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","671.39","59.3","","720.78","230.14","2010.94","427","566.1","888.21","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","671.39","59.3","","344.45","344.45","344.45","1 through 10","566.1","888.21","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","1120.13","1120.13","1120.13","1 through 10","566.1","888.21","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","456.17","105.33","1284.66","242","566.1","888.21","percent of total billed charges",""
"Phenobarbital","PX-30000186","CDM","80184","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","59.54","59.54","59.54","1 through 10","14.99","102.6","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","12.99","105.45","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","AETNA [1001]","HB CH AETNA HMO / PPO","338.14","58.3","","319.79","319.79","319.79","25","145.42","451.88","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","14","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","MEDICARE [2001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","128","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","450.06","150.02","450.06","43","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","153.08","153.08","153.08","1 through 10","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","WELLPOINT [1015]","HB CH WELLPOINT","451.88","77.91","","444.21","444.21","444.21","1 through 10","145.42","451.88","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","580.00","435.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","343.94","59.3","","330.50","330.50","330.51","16","175.84","455.01","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","455.01","78.45","","433.60","256.96","433.60","1 through 10","175.84","455.01","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","17","5.08","43.7","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","46.00","34.50","TRICARE [160005]","HB NWH TRICARE","43.70","95","","51.24","6.24","51.24","1 through 10","5.08","43.7","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","26.37","24","5.34","36.09","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","34.60","34.60","15","5.34","36.09","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","14.48","114","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","120.00","90.00","TRICARE [160005]","HB NWH TRICARE","114.00","95","","17.81","17.81","17.81","1 through 10","14.48","114","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","1 through 10","15.25","94.14","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","53.31","89.95","1 through 10","15.25","94.14","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","17.62","106.04","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","1 through 10","4.81","75.31","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","71.50","71.50","1 through 10","4.81","75.31","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0300","RC","","","","inpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.76","56","","26.37","24.88","26.37","1 through 10","25.76","32.48","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","136","4.65","43.7","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","33.58","73","","2.91","2.91","2.91","1 through 10","4.65","43.7","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","TRICARE [160005]","HB NWH TRICARE","43.70","95","","5.42","5.42","5.71","1 through 10","4.65","43.7","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.45","44.45","","33.37","33.37","34.60","11","4.65","43.7","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","79.11","201","4.87","36.09","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","20.50","34.60","120","4.87","36.09","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.81","1 through 10","5.66","40.85","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.50","59.3","","24.61","24.61","24.61","1 through 10","5.34","33.73","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","249.48","249.48","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","452.00","339.00","TRICARE [160005]","HB NWH TRICARE","429.40","95","","109.20","109.20","109.20","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.62","107.02","109.75","1 through 10","107.02","429.4","fee schedule",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.59","78.45","","232.00","232.00","232.00","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","249.48","249.48","83","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","239.56","53","","233.20","233.20","233.20","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","329.96","73","","349.00","349.00","349.00","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","TRICARE [160005]","HB NWH TRICARE","429.40","95","","111.59","103.74","111.59","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.15","80.11","109.35","110","107.02","429.4","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","WELLPOINT [1015]","HB CH WELLPOINT","352.15","77.91","","346.54","346.54","346.54","32","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","452.00","339.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.04","59.3","","257.84","257.84","257.84","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","268.04","59.3","","257.75","257.75","257.75","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.59","78.45","","167.89","167.89","167.89","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","249.48","249.48","42","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","TRICARE [160005]","HB NWH TRICARE","429.40","95","","109.20","109.20","109.20","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.02","79.51","109.20","92","107.02","429.4","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","WELLPOINT [1015]","HB CH WELLPOINT","352.15","77.91","","346.54","330.67","346.54","1 through 10","107.02","429.4","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","452.00","339.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.04","59.3","","356.29","356.29","356.29","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Re-Eval Est Plan Care 20 Mins","PX-42000103","CDM","97164","CPT","0424","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","171.80","171.80","171.80","1 through 10","74.39","364.8","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","AETNA [1001]","HB CH AETNA HMO / PPO","666.79","58.3","","464.71","67.87","1012.10","221","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","666.79","58.3","","293.04","293.04","293.04","11","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","606.17","53","","983.89","983.89","983.89","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","663.36","58","","677.18","677.18","677.18","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","714.83","62.5","","46.58","46.58","46.58","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","834.92","73","","747.15","747.15","747.15","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.38","44.45","","1141.67","481.21","1141.67","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.38","44.45","","76.54","76.54","76.54","1 through 10","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.72","857.79","WELLPOINT [1015]","HB CH WELLPOINT","891.07","77.91","","273.64","94.28","1367.51","138","508.38","891.07","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.72","857.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","678.23","59.3","","720.78","230.14","2010.94","427","571.86","897.25","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.72","857.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","678.23","59.3","","344.45","344.45","344.45","1 through 10","571.86","897.25","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.72","857.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","897.25","78.45","","1120.13","1120.13","1120.13","1 through 10","571.86","897.25","percent of total billed charges",""
"PIN ANCHORING 4X35MM NAVIGATION","SUP-ITM-10101402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.72","857.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","897.25","78.45","","456.17","105.33","1284.66","242","571.86","897.25","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","AETNA [1001]","HB CH AETNA HMO / PPO","549.19","58.3","","464.71","67.87","1012.10","221","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.19","58.3","","293.04","293.04","293.04","11","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.26","53","","983.89","983.89","983.89","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","546.36","58","","677.18","677.18","677.18","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","588.75","62.5","","46.58","46.58","46.58","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.66","73","","747.15","747.15","747.15","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.72","44.45","","1141.67","481.21","1141.67","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.72","44.45","","76.54","76.54","76.54","1 through 10","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","WELLPOINT [1015]","HB CH WELLPOINT","733.91","77.91","","273.64","94.28","1367.51","138","418.72","733.91","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.61","59.3","","720.78","230.14","2010.94","427","471","739","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","558.61","59.3","","344.45","344.45","344.45","1 through 10","471","739","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","739.00","78.45","","1120.13","1120.13","1120.13","1 through 10","471","739","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","739.00","78.45","","456.17","105.33","1284.66","242","471","739","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","AETNA [1001]","HB CH AETNA HMO / PPO","88.01","58.3","","464.71","67.87","1012.10","221","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","88.01","58.3","","293.04","293.04","293.04","11","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","80.01","53","","983.89","983.89","983.89","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.56","58","","677.18","677.18","677.18","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","94.35","62.5","","46.58","46.58","46.58","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.20","73","","747.15","747.15","747.15","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.10","44.45","","1141.67","481.21","1141.67","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.10","44.45","","76.54","76.54","76.54","1 through 10","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","WELLPOINT [1015]","HB CH WELLPOINT","117.61","77.91","","273.64","94.28","1367.51","138","67.1","117.61","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.52","59.3","","720.78","230.14","2010.94","427","75.48","118.43","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","89.52","59.3","","344.45","344.45","344.45","1 through 10","75.48","118.43","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","118.43","78.45","","1120.13","1120.13","1120.13","1 through 10","75.48","118.43","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.43","78.45","","456.17","105.33","1284.66","242","75.48","118.43","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","AETNA [1001]","HB CH AETNA HMO / PPO","79.60","58.3","","2190.90","412.50","9264.59","16","60.69","106.37","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","79.19","58","","1903.20","1903.20","3826.66","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","85.33","62.5","","2186.25","2186.25","2186.25","32","60.69","106.37","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","99.67","73","","5556.60","5556.60","5556.60","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","WELLPOINT [1015]","HB CH WELLPOINT","106.37","77.91","","1955.15","885.83","3150.40","26","60.69","106.37","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.96","59.3","","831.03","253.22","2394.88","18","68.27","107.11","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.11","78.45","","2481.69","1563.74","8149.28","1 through 10","68.27","107.11","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","464.71","67.87","1012.10","221","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","293.04","293.04","293.04","11","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","983.89","983.89","983.89","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","739.50","58","","677.18","677.18","677.18","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","796.88","62.5","","46.58","46.58","46.58","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","747.15","747.15","747.15","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","1141.67","481.21","1141.67","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","76.54","76.54","76.54","1 through 10","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","273.64","94.28","1367.51","138","566.74","993.35","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","720.78","230.14","2010.94","427","637.5","1000.24","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","756.08","59.3","","344.45","344.45","344.45","1 through 10","637.5","1000.24","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","1120.13","1120.13","1120.13","1 through 10","637.5","1000.24","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","456.17","105.33","1284.66","242","637.5","1000.24","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN BONE 110MM SPEED NONRIM BX/3EA","SUP-ITM-10198664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","AETNA [1001]","HB CH AETNA HMO / PPO","27.03","58.3","","464.71","67.87","1012.10","221","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","27.03","58.3","","293.04","293.04","293.04","11","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","24.57","53","","983.89","983.89","983.89","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","26.89","58","","677.18","677.18","677.18","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28.98","62.5","","46.58","46.58","46.58","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","33.84","73","","747.15","747.15","747.15","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.61","44.45","","1141.67","481.21","1141.67","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.61","44.45","","76.54","76.54","76.54","1 through 10","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","46.36","34.77","WELLPOINT [1015]","HB CH WELLPOINT","36.12","77.91","","273.64","94.28","1367.51","138","20.61","36.12","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","46.36","34.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.49","59.3","","720.78","230.14","2010.94","427","23.18","36.37","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","46.36","34.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","27.49","59.3","","344.45","344.45","344.45","1 through 10","23.18","36.37","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","46.36","34.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","36.37","78.45","","1120.13","1120.13","1120.13","1 through 10","23.18","36.37","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","46.36","34.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.37","78.45","","456.17","105.33","1284.66","242","23.18","36.37","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","AETNA [1001]","HB CH AETNA HMO / PPO","12.05","58.3","","464.71","67.87","1012.10","221","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","12.05","58.3","","293.04","293.04","293.04","11","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10.96","53","","983.89","983.89","983.89","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","11.99","58","","677.18","677.18","677.18","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","12.92","62.5","","46.58","46.58","46.58","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","15.09","73","","747.15","747.15","747.15","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.19","44.45","","1141.67","481.21","1141.67","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.19","44.45","","76.54","76.54","76.54","1 through 10","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","WELLPOINT [1015]","HB CH WELLPOINT","16.10","77.91","","273.64","94.28","1367.51","138","9.19","16.1","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","12.26","59.3","","720.78","230.14","2010.94","427","10.34","16.22","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","12.26","59.3","","344.45","344.45","344.45","1 through 10","10.34","16.22","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","16.22","78.45","","1120.13","1120.13","1120.13","1 through 10","10.34","16.22","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","16.22","78.45","","456.17","105.33","1284.66","242","10.34","16.22","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","AETNA [1001]","HB CH AETNA HMO / PPO","63.05","58.3","","464.71","67.87","1012.10","221","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","63.05","58.3","","293.04","293.04","293.04","11","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.32","53","","983.89","983.89","983.89","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","62.73","58","","677.18","677.18","677.18","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","67.59","62.5","","46.58","46.58","46.58","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.95","73","","747.15","747.15","747.15","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.07","44.45","","1141.67","481.21","1141.67","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.07","44.45","","76.54","76.54","76.54","1 through 10","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.15","81.11","WELLPOINT [1015]","HB CH WELLPOINT","84.26","77.91","","273.64","94.28","1367.51","138","48.07","84.26","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.15","81.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.13","59.3","","720.78","230.14","2010.94","427","54.08","84.84","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.15","81.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","64.13","59.3","","344.45","344.45","344.45","1 through 10","54.08","84.84","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.15","81.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","84.84","78.45","","1120.13","1120.13","1120.13","1 through 10","54.08","84.84","percent of total billed charges",""
"PIN BONE 2.8X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10075999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.15","81.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.84","78.45","","456.17","105.33","1284.66","242","54.08","84.84","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","AETNA [1001]","HB CH AETNA HMO / PPO","117.18","58.3","","464.71","67.87","1012.10","221","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.18","58.3","","293.04","293.04","293.04","11","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.53","53","","983.89","983.89","983.89","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","116.58","58","","677.18","677.18","677.18","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","125.63","62.5","","46.58","46.58","46.58","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","146.73","73","","747.15","747.15","747.15","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","44.45","","1141.67","481.21","1141.67","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","44.45","","76.54","76.54","76.54","1 through 10","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","WELLPOINT [1015]","HB CH WELLPOINT","156.60","77.91","","273.64","94.28","1367.51","138","89.34","156.6","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.19","59.3","","720.78","230.14","2010.94","427","100.5","157.68","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","119.19","59.3","","344.45","344.45","344.45","1 through 10","100.5","157.68","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","157.68","78.45","","1120.13","1120.13","1120.13","1 through 10","100.5","157.68","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","157.68","78.45","","456.17","105.33","1284.66","242","100.5","157.68","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","AETNA [1001]","HB CH AETNA HMO / PPO","42.03","58.3","","464.71","67.87","1012.10","221","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","42.03","58.3","","293.04","293.04","293.04","11","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","38.21","53","","983.89","983.89","983.89","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","41.82","58","","677.18","677.18","677.18","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","45.06","62.5","","46.58","46.58","46.58","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","52.63","73","","747.15","747.15","747.15","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.05","44.45","","1141.67","481.21","1141.67","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.05","44.45","","76.54","76.54","76.54","1 through 10","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","WELLPOINT [1015]","HB CH WELLPOINT","56.17","77.91","","273.64","94.28","1367.51","138","32.05","56.17","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.76","59.3","","720.78","230.14","2010.94","427","36.05","56.56","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","42.76","59.3","","344.45","344.45","344.45","1 through 10","36.05","56.56","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","56.56","78.45","","1120.13","1120.13","1120.13","1 through 10","36.05","56.56","percent of total billed charges",""
"PIN BONE 3.2X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.56","78.45","","456.17","105.33","1284.66","242","36.05","56.56","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","AETNA [1001]","HB CH AETNA HMO / PPO","91.82","58.3","","464.71","67.87","1012.10","221","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.82","58.3","","293.04","293.04","293.04","11","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","83.48","53","","983.89","983.89","983.89","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","91.35","58","","677.18","677.18","677.18","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","98.44","62.5","","46.58","46.58","46.58","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.98","73","","747.15","747.15","747.15","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","1141.67","481.21","1141.67","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","76.54","76.54","76.54","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB CH WELLPOINT","122.71","77.91","","273.64","94.28","1367.51","138","70.01","122.71","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.40","59.3","","720.78","230.14","2010.94","427","78.75","123.56","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","93.40","59.3","","344.45","344.45","344.45","1 through 10","78.75","123.56","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","1120.13","1120.13","1120.13","1 through 10","78.75","123.56","percent of total billed charges",""
"PIN BONE 3.5IN TI QUICK RELEASE SHOULDER REVERSE SMOOTH HUMERAL HEAD PK/2EA","SUP-ITM-10207956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","456.17","105.33","1284.66","242","78.75","123.56","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","AETNA [1001]","HB CH AETNA HMO / PPO","15.71","58.3","","464.71","67.87","1012.10","221","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","15.71","58.3","","293.04","293.04","293.04","11","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","14.28","53","","983.89","983.89","983.89","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","15.63","58","","677.18","677.18","677.18","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","16.84","62.5","","46.58","46.58","46.58","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","19.67","73","","747.15","747.15","747.15","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11.97","44.45","","1141.67","481.21","1141.67","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11.97","44.45","","76.54","76.54","76.54","1 through 10","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.94","20.20","WELLPOINT [1015]","HB CH WELLPOINT","20.99","77.91","","273.64","94.28","1367.51","138","11.97","20.99","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.94","20.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","15.98","59.3","","720.78","230.14","2010.94","427","13.47","21.13","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.94","20.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","15.98","59.3","","344.45","344.45","344.45","1 through 10","13.47","21.13","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.94","20.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","21.13","78.45","","1120.13","1120.13","1120.13","1 through 10","13.47","21.13","percent of total billed charges",""
"PIN BONE 3.6X229MM STEINMANN SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6EA","SUP-ITM-10028363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.94","20.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","21.13","78.45","","456.17","105.33","1284.66","242","13.47","21.13","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","464.71","67.87","1012.10","221","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","293.04","293.04","293.04","11","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","983.89","983.89","983.89","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","504.60","58","","677.18","677.18","677.18","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","543.75","62.5","","46.58","46.58","46.58","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","747.15","747.15","747.15","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","1141.67","481.21","1141.67","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","76.54","76.54","76.54","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","273.64","94.28","1367.51","138","386.72","677.82","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","720.78","230.14","2010.94","427","435","682.52","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","515.91","59.3","","344.45","344.45","344.45","1 through 10","435","682.52","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","1120.13","1120.13","1120.13","1 through 10","435","682.52","percent of total billed charges",""
"PIN BONE 32MM TRIMED DORSAL BUTTRESS WRIST FIXATION","SUP-ITM-10005623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","456.17","105.33","1284.66","242","435","682.52","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","464.71","67.87","1012.10","221","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.88","58.3","","293.04","293.04","293.04","11","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","983.89","983.89","983.89","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.50","58","","677.18","677.18","677.18","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.13","62.5","","46.58","46.58","46.58","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","747.15","747.15","747.15","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","1141.67","481.21","1141.67","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","76.54","76.54","76.54","1 through 10","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","273.64","94.28","1367.51","138","500.06","876.49","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","720.78","230.14","2010.94","427","562.5","882.56","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.13","59.3","","344.45","344.45","344.45","1 through 10","562.5","882.56","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","1120.13","1120.13","1120.13","1 through 10","562.5","882.56","percent of total billed charges",""
"PIN BONE 32MM VOLAR BUTTRESS SS","SUP-ITM-10028334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","456.17","105.33","1284.66","242","562.5","882.56","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","464.71","67.87","1012.10","221","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.61","58.3","","293.04","293.04","293.04","11","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.55","53","","983.89","983.89","983.89","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","252.30","58","","677.18","677.18","677.18","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","271.88","62.5","","46.58","46.58","46.58","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","747.15","747.15","747.15","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","1141.67","481.21","1141.67","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","76.54","76.54","76.54","1 through 10","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","273.64","94.28","1367.51","138","193.36","338.91","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","720.78","230.14","2010.94","427","217.5","341.26","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","257.96","59.3","","344.45","344.45","344.45","1 through 10","217.5","341.26","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","1120.13","1120.13","1120.13","1 through 10","217.5","341.26","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","456.17","105.33","1284.66","242","217.5","341.26","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","AETNA [1001]","HB CH AETNA HMO / PPO","155.59","58.3","","464.71","67.87","1012.10","221","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","155.59","58.3","","293.04","293.04","293.04","11","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.45","53","","983.89","983.89","983.89","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","154.79","58","","677.18","677.18","677.18","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","166.80","62.5","","46.58","46.58","46.58","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.82","73","","747.15","747.15","747.15","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.63","44.45","","1141.67","481.21","1141.67","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.63","44.45","","76.54","76.54","76.54","1 through 10","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.88","200.16","WELLPOINT [1015]","HB CH WELLPOINT","207.93","77.91","","273.64","94.28","1367.51","138","118.63","207.93","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.88","200.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.26","59.3","","720.78","230.14","2010.94","427","133.44","209.37","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.88","200.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.26","59.3","","344.45","344.45","344.45","1 through 10","133.44","209.37","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.88","200.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","209.37","78.45","","1120.13","1120.13","1120.13","1 through 10","133.44","209.37","percent of total billed charges",""
"PIN BONE 5X200MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.88","200.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.37","78.45","","456.17","105.33","1284.66","242","133.44","209.37","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","464.71","67.87","1012.10","221","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8.75","58.3","","293.04","293.04","293.04","11","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","983.89","983.89","983.89","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8.70","58","","677.18","677.18","677.18","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9.38","62.5","","46.58","46.58","46.58","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","747.15","747.15","747.15","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.67","44.45","","1141.67","481.21","1141.67","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.67","44.45","","76.54","76.54","76.54","1 through 10","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","273.64","94.28","1367.51","138","6.67","11.69","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","720.78","230.14","2010.94","427","7.5","11.77","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","8.90","59.3","","344.45","344.45","344.45","1 through 10","7.5","11.77","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","1120.13","1120.13","1120.13","1 through 10","7.5","11.77","percent of total billed charges",""
"PIN BONE 9.0IN 0.078 STEINMANN HOFFMAN II SS SMOOTH TROCAR POINT","SUP-ITM-10028298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","456.17","105.33","1284.66","242","7.5","11.77","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","AETNA [1001]","HB CH AETNA HMO / PPO","237.79","58.3","","464.71","67.87","1012.10","221","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.79","58.3","","293.04","293.04","293.04","11","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.18","53","","983.89","983.89","983.89","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","236.57","58","","677.18","677.18","677.18","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","254.93","62.5","","46.58","46.58","46.58","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.75","73","","747.15","747.15","747.15","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.30","44.45","","1141.67","481.21","1141.67","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.30","44.45","","76.54","76.54","76.54","1 through 10","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","WELLPOINT [1015]","HB CH WELLPOINT","317.78","77.91","","273.64","94.28","1367.51","138","181.3","317.78","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.87","59.3","","720.78","230.14","2010.94","427","203.94","319.98","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","241.87","59.3","","344.45","344.45","344.45","1 through 10","203.94","319.98","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","319.98","78.45","","1120.13","1120.13","1120.13","1 through 10","203.94","319.98","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","319.98","78.45","","456.17","105.33","1284.66","242","203.94","319.98","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","AETNA [1001]","HB CH AETNA HMO / PPO","163.99","58.3","","464.71","67.87","1012.10","221","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.99","58.3","","293.04","293.04","293.04","11","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","149.08","53","","983.89","983.89","983.89","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","163.14","58","","677.18","677.18","677.18","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","175.80","62.5","","46.58","46.58","46.58","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","205.33","73","","747.15","747.15","747.15","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","125.03","44.45","","1141.67","481.21","1141.67","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","125.03","44.45","","76.54","76.54","76.54","1 through 10","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","WELLPOINT [1015]","HB CH WELLPOINT","219.15","77.91","","273.64","94.28","1367.51","138","125.03","219.15","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.80","59.3","","720.78","230.14","2010.94","427","140.64","220.66","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","166.80","59.3","","344.45","344.45","344.45","1 through 10","140.64","220.66","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","220.66","78.45","","1120.13","1120.13","1120.13","1 through 10","140.64","220.66","percent of total billed charges",""
"PIN BUTTRESS 1.8X12MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.66","78.45","","456.17","105.33","1284.66","242","140.64","220.66","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","AETNA [1001]","HB CH AETNA HMO / PPO","389.33","58.3","","464.71","67.87","1012.10","221","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","389.33","58.3","","293.04","293.04","293.04","11","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","353.93","53","","983.89","983.89","983.89","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","387.32","58","","677.18","677.18","677.18","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","417.38","62.5","","46.58","46.58","46.58","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","487.49","73","","747.15","747.15","747.15","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.84","44.45","","1141.67","481.21","1141.67","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.84","44.45","","76.54","76.54","76.54","1 through 10","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","WELLPOINT [1015]","HB CH WELLPOINT","520.28","77.91","","273.64","94.28","1367.51","138","296.84","520.28","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","396.01","59.3","","720.78","230.14","2010.94","427","333.9","523.89","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","396.01","59.3","","344.45","344.45","344.45","1 through 10","333.9","523.89","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","523.89","78.45","","1120.13","1120.13","1120.13","1 through 10","333.9","523.89","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.89","78.45","","456.17","105.33","1284.66","242","333.9","523.89","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","AETNA [1001]","HB CH AETNA HMO / PPO","91.82","58.3","","2190.90","412.50","9264.59","16","70.01","122.71","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","91.35","58","","1903.20","1903.20","3826.66","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","98.44","62.5","","2186.25","2186.25","2186.25","32","70.01","122.71","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.98","73","","5556.60","5556.60","5556.60","1 through 10","70.01","122.71","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB CH WELLPOINT","122.71","77.91","","1955.15","885.83","3150.40","26","70.01","122.71","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.40","59.3","","831.03","253.22","2394.88","18","78.75","123.56","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","2481.69","1563.74","8149.28","1 through 10","78.75","123.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","AETNA [1001]","HB CH AETNA HMO / PPO","79.60","58.3","","464.71","67.87","1012.10","221","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","79.60","58.3","","293.04","293.04","293.04","11","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","72.36","53","","983.89","983.89","983.89","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","79.19","58","","677.18","677.18","677.18","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","85.33","62.5","","46.58","46.58","46.58","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","99.67","73","","747.15","747.15","747.15","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.69","44.45","","1141.67","481.21","1141.67","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.69","44.45","","76.54","76.54","76.54","1 through 10","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","WELLPOINT [1015]","HB CH WELLPOINT","106.37","77.91","","273.64","94.28","1367.51","138","60.69","106.37","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.96","59.3","","720.78","230.14","2010.94","427","68.27","107.11","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.96","59.3","","344.45","344.45","344.45","1 through 10","68.27","107.11","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","107.11","78.45","","1120.13","1120.13","1120.13","1 through 10","68.27","107.11","percent of total billed charges",""
"PIN PLATE 1.8MM /30 BUTTRESS SS DISTAL","SUP-ITM-10006550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.11","78.45","","456.17","105.33","1284.66","242","68.27","107.11","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"PIN SE 3.6X14MM","SUP-ITM-10155781","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","5530.54","5530.54","5530.54","1 through 10","90","141.21","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","464.71","67.87","1012.10","221","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.64","58.3","","293.04","293.04","293.04","11","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.40","53","","983.89","983.89","983.89","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","46.40","58","","677.18","677.18","677.18","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","50.00","62.5","","46.58","46.58","46.58","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","747.15","747.15","747.15","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","1141.67","481.21","1141.67","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","76.54","76.54","76.54","1 through 10","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","WELLPOINT [1015]","HB CH WELLPOINT","62.33","77.91","","273.64","94.28","1367.51","138","35.56","62.33","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","720.78","230.14","2010.94","427","40","62.76","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","47.44","59.3","","344.45","344.45","344.45","1 through 10","40","62.76","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","1120.13","1120.13","1120.13","1 through 10","40","62.76","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","456.17","105.33","1284.66","242","40","62.76","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","464.71","67.87","1012.10","221","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","293.04","293.04","293.04","11","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","983.89","983.89","983.89","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","139.20","58","","677.18","677.18","677.18","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","150.00","62.5","","46.58","46.58","46.58","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","747.15","747.15","747.15","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","1141.67","481.21","1141.67","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","76.54","76.54","76.54","1 through 10","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","273.64","94.28","1367.51","138","106.68","186.98","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","720.78","230.14","2010.94","427","120","188.28","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","142.32","59.3","","344.45","344.45","344.45","1 through 10","120","188.28","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","1120.13","1120.13","1120.13","1 through 10","120","188.28","percent of total billed charges",""
"PIN STEINMANN 3.2X178MM BONE EQUINOXE","SUP-ITM-10285732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","456.17","105.33","1284.66","242","120","188.28","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","464.71","67.87","1012.10","221","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","293.04","293.04","293.04","11","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","983.89","983.89","983.89","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","677.18","677.18","677.18","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","46.58","46.58","46.58","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","747.15","747.15","747.15","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","1141.67","481.21","1141.67","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","76.54","76.54","76.54","1 through 10","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","273.64","94.28","1367.51","138","60.01","105.18","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","720.78","230.14","2010.94","427","67.5","105.91","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","344.45","344.45","344.45","1 through 10","67.5","105.91","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1120.13","1120.13","1120.13","1 through 10","67.5","105.91","percent of total billed charges",""
"PIN STEINMANN SHARP SHORT","SUP-ITM-10319037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","456.17","105.33","1284.66","242","67.5","105.91","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","AETNA [1001]","HB CH AETNA HMO / PPO","156.15","58.3","","464.71","67.87","1012.10","221","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.15","58.3","","293.04","293.04","293.04","11","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.96","53","","983.89","983.89","983.89","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","155.35","58","","677.18","677.18","677.18","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","167.40","62.5","","46.58","46.58","46.58","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.52","73","","747.15","747.15","747.15","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.05","44.45","","1141.67","481.21","1141.67","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.05","44.45","","76.54","76.54","76.54","1 through 10","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","WELLPOINT [1015]","HB CH WELLPOINT","208.67","77.91","","273.64","94.28","1367.51","138","119.05","208.67","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.83","59.3","","720.78","230.14","2010.94","427","133.92","210.12","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.83","59.3","","344.45","344.45","344.45","1 through 10","133.92","210.12","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","210.12","78.45","","1120.13","1120.13","1120.13","1 through 10","133.92","210.12","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.12","78.45","","456.17","105.33","1284.66","242","133.92","210.12","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","464.71","67.87","1012.10","221","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","293.04","293.04","293.04","11","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","983.89","983.89","983.89","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","504.60","58","","677.18","677.18","677.18","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","543.75","62.5","","46.58","46.58","46.58","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","747.15","747.15","747.15","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","1141.67","481.21","1141.67","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","76.54","76.54","76.54","1 through 10","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","273.64","94.28","1367.51","138","386.72","677.82","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","720.78","230.14","2010.94","427","435","682.52","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","515.91","59.3","","344.45","344.45","344.45","1 through 10","435","682.52","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","1120.13","1120.13","1120.13","1 through 10","435","682.52","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","456.17","105.33","1284.66","242","435","682.52","percent of total billed charges",""
"Pinworm Exam Cellophane Tape Prep","PX-30001180","CDM","87172","CPT","0306","RC","","","","both","","","40.00","30.00","AETNA [1001]","HB CH AETNA HMO / PPO","23.32","58.3","","22.11","22.11","22.11","1 through 10","4.18","38","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","14.75","122.55","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","AETNA [1001]","HB CH AETNA HMO / PPO","217.46","58.3","","205.82","205.82","205.82","1 through 10","165.8","1456.11","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","MEDICARE [2001]","HB NWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","12","165.8","1456.11","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","165.8","1456.11","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","165.8","1456.11","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","373.00","279.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","221.19","59.3","","212.72","212.72","212.72","1 through 10","186.5","926.86","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","292.62","78.45","","279.07","279.07","279.07","1 through 10","186.5","926.86","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1819.52","49.07","","3775.00","3775.00","3775.00","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1857.71","50.1","","3860.43","3860.43","3860.43","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2908.93","78.45","","4589.74","4589.74","4589.74","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","both","","","510.00","382.50","MEDICARE [2001]","HB NWH MEDICARE","71.09","","APC Price ($71.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71.09","71.09","71.09","1 through 10","67.54","485.01","other","OPPS APC"
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","AETNA [1001]","HB CH AETNA HMO / PPO","2131.59","58.3","","464.71","67.87","1012.10","221","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","293.04","293.04","293.04","11","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.81","53","","983.89","983.89","983.89","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2120.63","58","","677.18","677.18","677.18","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2285.16","62.5","","46.58","46.58","46.58","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","747.15","747.15","747.15","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","1141.67","481.21","1141.67","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","76.54","76.54","76.54","1 through 10","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","WELLPOINT [1015]","HB CH WELLPOINT","2848.58","77.91","","273.64","94.28","1367.51","138","1625.2","2848.58","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","720.78","230.14","2010.94","427","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2168.16","59.3","","344.45","344.45","344.45","1 through 10","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","1120.13","1120.13","1120.13","1 through 10","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","456.17","105.33","1284.66","242","1828.13","2868.33","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","AETNA [1001]","HB CH AETNA HMO / PPO","2079.56","58.3","","464.71","67.87","1012.10","221","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2079.56","58.3","","293.04","293.04","293.04","11","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1890.51","53","","983.89","983.89","983.89","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2068.86","58","","677.18","677.18","677.18","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2229.38","62.5","","46.58","46.58","46.58","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.91","73","","747.15","747.15","747.15","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.53","44.45","","1141.67","481.21","1141.67","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.53","44.45","","76.54","76.54","76.54","1 through 10","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","WELLPOINT [1015]","HB CH WELLPOINT","2779.05","77.91","","273.64","94.28","1367.51","138","1585.53","2779.05","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2115.23","59.3","","720.78","230.14","2010.94","427","1783.5","2798.31","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2115.23","59.3","","344.45","344.45","344.45","1 through 10","1783.5","2798.31","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2798.31","78.45","","1120.13","1120.13","1120.13","1 through 10","1783.5","2798.31","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2798.31","78.45","","456.17","105.33","1284.66","242","1783.5","2798.31","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","AETNA [1001]","HB CH AETNA HMO / PPO","966.17","58.3","","464.71","67.87","1012.10","221","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","966.17","58.3","","293.04","293.04","293.04","11","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","878.33","53","","983.89","983.89","983.89","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","961.19","58","","677.18","677.18","677.18","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1035.77","62.5","","46.58","46.58","46.58","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1209.78","73","","747.15","747.15","747.15","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.64","44.45","","1141.67","481.21","1141.67","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.64","44.45","","76.54","76.54","76.54","1 through 10","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1657.23","1242.92","WELLPOINT [1015]","HB CH WELLPOINT","1291.15","77.91","","273.64","94.28","1367.51","138","736.64","1291.15","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1657.23","1242.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","982.74","59.3","","720.78","230.14","2010.94","427","828.62","1300.1","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1657.23","1242.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","982.74","59.3","","344.45","344.45","344.45","1 through 10","828.62","1300.1","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1657.23","1242.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1300.10","78.45","","1120.13","1120.13","1120.13","1 through 10","828.62","1300.1","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1657.23","1242.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1300.10","78.45","","456.17","105.33","1284.66","242","828.62","1300.1","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","AETNA [1001]","HB CH AETNA HMO / PPO","2264.48","58.3","","464.71","67.87","1012.10","221","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2264.48","58.3","","293.04","293.04","293.04","11","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2058.62","53","","983.89","983.89","983.89","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2252.83","58","","677.18","677.18","677.18","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2427.62","62.5","","46.58","46.58","46.58","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2835.46","73","","747.15","747.15","747.15","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.52","44.45","","1141.67","481.21","1141.67","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.52","44.45","","76.54","76.54","76.54","1 through 10","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","WELLPOINT [1015]","HB CH WELLPOINT","3026.17","77.91","","273.64","94.28","1367.51","138","1726.52","3026.17","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.32","59.3","","720.78","230.14","2010.94","427","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2303.32","59.3","","344.45","344.45","344.45","1 through 10","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3047.15","78.45","","1120.13","1120.13","1120.13","1 through 10","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.15","78.45","","456.17","105.33","1284.66","242","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","AETNA [1001]","HB CH AETNA HMO / PPO","1966.84","58.3","","464.71","67.87","1012.10","221","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1966.84","58.3","","293.04","293.04","293.04","11","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.03","53","","983.89","983.89","983.89","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1956.72","58","","677.18","677.18","677.18","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2108.53","62.5","","46.58","46.58","46.58","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2462.76","73","","747.15","747.15","747.15","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1499.59","44.45","","1141.67","481.21","1141.67","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1499.59","44.45","","76.54","76.54","76.54","1 through 10","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3373.65","2530.24","WELLPOINT [1015]","HB CH WELLPOINT","2628.41","77.91","","273.64","94.28","1367.51","138","1499.59","2628.41","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3373.65","2530.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","2000.57","59.3","","720.78","230.14","2010.94","427","1686.83","2646.63","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3373.65","2530.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2000.57","59.3","","344.45","344.45","344.45","1 through 10","1686.83","2646.63","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3373.65","2530.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2646.63","78.45","","1120.13","1120.13","1120.13","1 through 10","1686.83","2646.63","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3373.65","2530.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2646.63","78.45","","456.17","105.33","1284.66","242","1686.83","2646.63","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","AETNA [1001]","HB CH AETNA HMO / PPO","322.27","58.3","","464.71","67.87","1012.10","221","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","322.27","58.3","","293.04","293.04","293.04","11","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","292.97","53","","983.89","983.89","983.89","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","320.61","58","","677.18","677.18","677.18","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","345.49","62.5","","46.58","46.58","46.58","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","403.53","73","","747.15","747.15","747.15","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.71","44.45","","1141.67","481.21","1141.67","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.71","44.45","","76.54","76.54","76.54","1 through 10","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","WELLPOINT [1015]","HB CH WELLPOINT","430.67","77.91","","273.64","94.28","1367.51","138","245.71","430.67","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","327.80","59.3","","720.78","230.14","2010.94","427","276.39","433.66","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","327.80","59.3","","344.45","344.45","344.45","1 through 10","276.39","433.66","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","433.66","78.45","","1120.13","1120.13","1120.13","1 through 10","276.39","433.66","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","433.66","78.45","","456.17","105.33","1284.66","242","276.39","433.66","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","AETNA [1001]","HB CH AETNA HMO / PPO","4541.57","58.3","","464.71","67.87","1012.10","221","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4541.57","58.3","","293.04","293.04","293.04","11","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4128.70","53","","983.89","983.89","983.89","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4518.20","58","","677.18","677.18","677.18","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4868.75","62.5","","46.58","46.58","46.58","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5686.70","73","","747.15","747.15","747.15","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3462.66","44.45","","1141.67","481.21","1141.67","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3462.66","44.45","","76.54","76.54","76.54","1 through 10","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","both","","","7790.00","5842.50","WELLPOINT [1015]","HB CH WELLPOINT","6069.19","77.91","","273.64","94.28","1367.51","138","3462.66","6069.19","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7790.00","5842.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4619.47","59.3","","720.78","230.14","2010.94","427","3895","6111.26","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7790.00","5842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4619.47","59.3","","344.45","344.45","344.45","1 through 10","3895","6111.26","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7790.00","5842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","6111.26","78.45","","1120.13","1120.13","1120.13","1 through 10","3895","6111.26","percent of total billed charges",""
"PLATE BONE 1 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7790.00","5842.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6111.26","78.45","","456.17","105.33","1284.66","242","3895","6111.26","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","AETNA [1001]","HB CH AETNA HMO / PPO","1980.74","58.3","","464.71","67.87","1012.10","221","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1980.74","58.3","","293.04","293.04","293.04","11","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1800.68","53","","983.89","983.89","983.89","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1970.55","58","","677.18","677.18","677.18","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2123.44","62.5","","46.58","46.58","46.58","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2480.18","73","","747.15","747.15","747.15","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.19","44.45","","1141.67","481.21","1141.67","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.19","44.45","","76.54","76.54","76.54","1 through 10","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.50","2548.12","WELLPOINT [1015]","HB CH WELLPOINT","2646.99","77.91","","273.64","94.28","1367.51","138","1510.19","2646.99","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.50","2548.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2014.72","59.3","","720.78","230.14","2010.94","427","1698.75","2665.34","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.50","2548.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2014.72","59.3","","344.45","344.45","344.45","1 through 10","1698.75","2665.34","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.50","2548.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2665.34","78.45","","1120.13","1120.13","1120.13","1 through 10","1698.75","2665.34","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.50","2548.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2665.34","78.45","","456.17","105.33","1284.66","242","1698.75","2665.34","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","AETNA [1001]","HB CH AETNA HMO / PPO","553.94","58.3","","464.71","67.87","1012.10","221","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","553.94","58.3","","293.04","293.04","293.04","11","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","503.58","53","","983.89","983.89","983.89","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","551.09","58","","677.18","677.18","677.18","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","593.85","62.5","","46.58","46.58","46.58","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","693.62","73","","747.15","747.15","747.15","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.35","44.45","","1141.67","481.21","1141.67","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.35","44.45","","76.54","76.54","76.54","1 through 10","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","WELLPOINT [1015]","HB CH WELLPOINT","740.27","77.91","","273.64","94.28","1367.51","138","422.35","740.27","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","563.44","59.3","","720.78","230.14","2010.94","427","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","563.44","59.3","","344.45","344.45","344.45","1 through 10","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","745.40","78.45","","1120.13","1120.13","1120.13","1 through 10","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","745.40","78.45","","456.17","105.33","1284.66","242","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","AETNA [1001]","HB CH AETNA HMO / PPO","581.77","58.3","","464.71","67.87","1012.10","221","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","581.77","58.3","","293.04","293.04","293.04","11","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","528.88","53","","983.89","983.89","983.89","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","578.78","58","","677.18","677.18","677.18","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","623.68","62.5","","46.58","46.58","46.58","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","728.46","73","","747.15","747.15","747.15","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.56","44.45","","1141.67","481.21","1141.67","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.56","44.45","","76.54","76.54","76.54","1 through 10","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.89","748.42","WELLPOINT [1015]","HB CH WELLPOINT","777.46","77.91","","273.64","94.28","1367.51","138","443.56","777.46","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.89","748.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","591.75","59.3","","720.78","230.14","2010.94","427","498.95","782.84","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.89","748.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","591.75","59.3","","344.45","344.45","344.45","1 through 10","498.95","782.84","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.89","748.42","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","782.84","78.45","","1120.13","1120.13","1120.13","1 through 10","498.95","782.84","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.89","748.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","782.84","78.45","","456.17","105.33","1284.66","242","498.95","782.84","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","AETNA [1001]","HB CH AETNA HMO / PPO","598.60","58.3","","464.71","67.87","1012.10","221","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","598.60","58.3","","293.04","293.04","293.04","11","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","544.18","53","","983.89","983.89","983.89","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","595.52","58","","677.18","677.18","677.18","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","641.72","62.5","","46.58","46.58","46.58","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","749.53","73","","747.15","747.15","747.15","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","456.39","44.45","","1141.67","481.21","1141.67","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","456.39","44.45","","76.54","76.54","76.54","1 through 10","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","WELLPOINT [1015]","HB CH WELLPOINT","799.94","77.91","","273.64","94.28","1367.51","138","456.39","799.94","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","608.86","59.3","","720.78","230.14","2010.94","427","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","608.86","59.3","","344.45","344.45","344.45","1 through 10","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","805.49","78.45","","1120.13","1120.13","1120.13","1 through 10","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","805.49","78.45","","456.17","105.33","1284.66","242","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","AETNA [1001]","HB CH AETNA HMO / PPO","557.83","58.3","","464.71","67.87","1012.10","221","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","557.83","58.3","","293.04","293.04","293.04","11","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","507.11","53","","983.89","983.89","983.89","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","554.96","58","","677.18","677.18","677.18","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","598.01","62.5","","46.58","46.58","46.58","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","698.48","73","","747.15","747.15","747.15","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.31","44.45","","1141.67","481.21","1141.67","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.31","44.45","","76.54","76.54","76.54","1 through 10","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","WELLPOINT [1015]","HB CH WELLPOINT","745.46","77.91","","273.64","94.28","1367.51","138","425.31","745.46","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","567.39","59.3","","720.78","230.14","2010.94","427","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","567.39","59.3","","344.45","344.45","344.45","1 through 10","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","750.63","78.45","","1120.13","1120.13","1120.13","1 through 10","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","750.63","78.45","","456.17","105.33","1284.66","242","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","AETNA [1001]","HB CH AETNA HMO / PPO","716.37","58.3","","464.71","67.87","1012.10","221","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","716.37","58.3","","293.04","293.04","293.04","11","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","651.25","53","","983.89","983.89","983.89","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","712.69","58","","677.18","677.18","677.18","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","767.98","62.5","","46.58","46.58","46.58","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","897.00","73","","747.15","747.15","747.15","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","546.19","44.45","","1141.67","481.21","1141.67","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","546.19","44.45","","76.54","76.54","76.54","1 through 10","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1228.77","921.58","WELLPOINT [1015]","HB CH WELLPOINT","957.33","77.91","","273.64","94.28","1367.51","138","546.19","957.33","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1228.77","921.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","728.66","59.3","","720.78","230.14","2010.94","427","614.39","963.97","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1228.77","921.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","728.66","59.3","","344.45","344.45","344.45","1 through 10","614.39","963.97","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1228.77","921.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","963.97","78.45","","1120.13","1120.13","1120.13","1 through 10","614.39","963.97","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1228.77","921.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","963.97","78.45","","456.17","105.33","1284.66","242","614.39","963.97","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","AETNA [1001]","HB CH AETNA HMO / PPO","547.47","58.3","","464.71","67.87","1012.10","221","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","547.47","58.3","","293.04","293.04","293.04","11","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","497.70","53","","983.89","983.89","983.89","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","544.65","58","","677.18","677.18","677.18","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","586.91","62.5","","46.58","46.58","46.58","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","685.51","73","","747.15","747.15","747.15","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.41","44.45","","1141.67","481.21","1141.67","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.41","44.45","","76.54","76.54","76.54","1 through 10","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","WELLPOINT [1015]","HB CH WELLPOINT","731.62","77.91","","273.64","94.28","1367.51","138","417.41","731.62","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","556.86","59.3","","720.78","230.14","2010.94","427","469.53","736.69","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","556.86","59.3","","344.45","344.45","344.45","1 through 10","469.53","736.69","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","736.69","78.45","","1120.13","1120.13","1120.13","1 through 10","469.53","736.69","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","736.69","78.45","","456.17","105.33","1284.66","242","469.53","736.69","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","AETNA [1001]","HB CH AETNA HMO / PPO","427.75","58.3","","464.71","67.87","1012.10","221","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","427.75","58.3","","293.04","293.04","293.04","11","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","388.87","53","","983.89","983.89","983.89","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","425.55","58","","677.18","677.18","677.18","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","458.57","62.5","","46.58","46.58","46.58","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","535.61","73","","747.15","747.15","747.15","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.13","44.45","","1141.67","481.21","1141.67","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.13","44.45","","76.54","76.54","76.54","1 through 10","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","WELLPOINT [1015]","HB CH WELLPOINT","571.63","77.91","","273.64","94.28","1367.51","138","326.13","571.63","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.09","59.3","","720.78","230.14","2010.94","427","366.86","575.6","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","435.09","59.3","","344.45","344.45","344.45","1 through 10","366.86","575.6","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","575.60","78.45","","1120.13","1120.13","1120.13","1 through 10","366.86","575.6","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","575.60","78.45","","456.17","105.33","1284.66","242","366.86","575.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","AETNA [1001]","HB CH AETNA HMO / PPO","685.96","58.3","","464.71","67.87","1012.10","221","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","685.96","58.3","","293.04","293.04","293.04","11","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","623.60","53","","983.89","983.89","983.89","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","682.43","58","","677.18","677.18","677.18","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","735.38","62.5","","46.58","46.58","46.58","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","858.92","73","","747.15","747.15","747.15","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.00","44.45","","1141.67","481.21","1141.67","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.00","44.45","","76.54","76.54","76.54","1 through 10","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","WELLPOINT [1015]","HB CH WELLPOINT","916.69","77.91","","273.64","94.28","1367.51","138","523","916.69","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","697.72","59.3","","720.78","230.14","2010.94","427","588.3","923.04","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","697.72","59.3","","344.45","344.45","344.45","1 through 10","588.3","923.04","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","923.04","78.45","","1120.13","1120.13","1120.13","1 through 10","588.3","923.04","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","923.04","78.45","","456.17","105.33","1284.66","242","588.3","923.04","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","AETNA [1001]","HB CH AETNA HMO / PPO","236.85","58.3","","464.71","67.87","1012.10","221","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","236.85","58.3","","293.04","293.04","293.04","11","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","215.32","53","","983.89","983.89","983.89","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","235.63","58","","677.18","677.18","677.18","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","253.91","62.5","","46.58","46.58","46.58","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","296.57","73","","747.15","747.15","747.15","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.58","44.45","","1141.67","481.21","1141.67","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.58","44.45","","76.54","76.54","76.54","1 through 10","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","WELLPOINT [1015]","HB CH WELLPOINT","316.52","77.91","","273.64","94.28","1367.51","138","180.58","316.52","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.91","59.3","","720.78","230.14","2010.94","427","203.13","318.71","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","240.91","59.3","","344.45","344.45","344.45","1 through 10","203.13","318.71","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","318.71","78.45","","1120.13","1120.13","1120.13","1 through 10","203.13","318.71","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","318.71","78.45","","456.17","105.33","1284.66","242","203.13","318.71","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","AETNA [1001]","HB CH AETNA HMO / PPO","261.44","58.3","","464.71","67.87","1012.10","221","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","261.44","58.3","","293.04","293.04","293.04","11","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.67","53","","983.89","983.89","983.89","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","260.10","58","","677.18","677.18","677.18","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","280.28","62.5","","46.58","46.58","46.58","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.36","73","","747.15","747.15","747.15","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.33","44.45","","1141.67","481.21","1141.67","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.33","44.45","","76.54","76.54","76.54","1 through 10","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","WELLPOINT [1015]","HB CH WELLPOINT","349.38","77.91","","273.64","94.28","1367.51","138","199.33","349.38","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","265.92","59.3","","720.78","230.14","2010.94","427","224.22","351.8","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","265.92","59.3","","344.45","344.45","344.45","1 through 10","224.22","351.8","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","351.80","78.45","","1120.13","1120.13","1120.13","1 through 10","224.22","351.8","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.80","78.45","","456.17","105.33","1284.66","242","224.22","351.8","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","AETNA [1001]","HB CH AETNA HMO / PPO","238.14","58.3","","464.71","67.87","1012.10","221","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","238.14","58.3","","293.04","293.04","293.04","11","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.49","53","","983.89","983.89","983.89","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","236.92","58","","677.18","677.18","677.18","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","255.30","62.5","","46.58","46.58","46.58","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","298.19","73","","747.15","747.15","747.15","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.57","44.45","","1141.67","481.21","1141.67","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.57","44.45","","76.54","76.54","76.54","1 through 10","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","WELLPOINT [1015]","HB CH WELLPOINT","318.25","77.91","","273.64","94.28","1367.51","138","181.57","318.25","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","242.23","59.3","","720.78","230.14","2010.94","427","204.24","320.45","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","242.23","59.3","","344.45","344.45","344.45","1 through 10","204.24","320.45","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","320.45","78.45","","1120.13","1120.13","1120.13","1 through 10","204.24","320.45","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.45","78.45","","456.17","105.33","1284.66","242","204.24","320.45","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","AETNA [1001]","HB CH AETNA HMO / PPO","454.93","58.3","","464.71","67.87","1012.10","221","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.93","58.3","","293.04","293.04","293.04","11","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.57","53","","983.89","983.89","983.89","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","452.59","58","","677.18","677.18","677.18","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","487.71","62.5","","46.58","46.58","46.58","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","569.64","73","","747.15","747.15","747.15","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.86","44.45","","1141.67","481.21","1141.67","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.86","44.45","","76.54","76.54","76.54","1 through 10","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","WELLPOINT [1015]","HB CH WELLPOINT","607.96","77.91","","273.64","94.28","1367.51","138","346.86","607.96","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.74","59.3","","720.78","230.14","2010.94","427","390.17","612.17","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","462.74","59.3","","344.45","344.45","344.45","1 through 10","390.17","612.17","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","612.17","78.45","","1120.13","1120.13","1120.13","1 through 10","390.17","612.17","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","612.17","78.45","","456.17","105.33","1284.66","242","390.17","612.17","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","AETNA [1001]","HB CH AETNA HMO / PPO","1320.50","58.3","","464.71","67.87","1012.10","221","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1320.50","58.3","","293.04","293.04","293.04","11","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1200.45","53","","983.89","983.89","983.89","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1313.70","58","","677.18","677.18","677.18","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1415.63","62.5","","46.58","46.58","46.58","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1653.45","73","","747.15","747.15","747.15","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1006.79","44.45","","1141.67","481.21","1141.67","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1006.79","44.45","","76.54","76.54","76.54","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","WELLPOINT [1015]","HB CH WELLPOINT","1764.66","77.91","","273.64","94.28","1367.51","138","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1343.15","59.3","","720.78","230.14","2010.94","427","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1343.15","59.3","","344.45","344.45","344.45","1 through 10","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1776.89","78.45","","1120.13","1120.13","1120.13","1 through 10","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 12MM TI","SUP-ITM-10270241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1776.89","78.45","","456.17","105.33","1284.66","242","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","AETNA [1001]","HB CH AETNA HMO / PPO","570.12","58.3","","464.71","67.87","1012.10","221","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.12","58.3","","293.04","293.04","293.04","11","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.29","53","","983.89","983.89","983.89","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","567.19","58","","677.18","677.18","677.18","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","611.19","62.5","","46.58","46.58","46.58","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.87","73","","747.15","747.15","747.15","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.68","44.45","","1141.67","481.21","1141.67","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.68","44.45","","76.54","76.54","76.54","1 through 10","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","WELLPOINT [1015]","HB CH WELLPOINT","761.89","77.91","","273.64","94.28","1367.51","138","434.68","761.89","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.90","59.3","","720.78","230.14","2010.94","427","488.96","767.17","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","579.90","59.3","","344.45","344.45","344.45","1 through 10","488.96","767.17","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","767.17","78.45","","1120.13","1120.13","1120.13","1 through 10","488.96","767.17","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.17","78.45","","456.17","105.33","1284.66","242","488.96","767.17","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","AETNA [1001]","HB CH AETNA HMO / PPO","242.67","58.3","","464.71","67.87","1012.10","221","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","242.67","58.3","","293.04","293.04","293.04","11","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","220.61","53","","983.89","983.89","983.89","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","241.43","58","","677.18","677.18","677.18","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","260.16","62.5","","46.58","46.58","46.58","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","303.86","73","","747.15","747.15","747.15","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.02","44.45","","1141.67","481.21","1141.67","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.02","44.45","","76.54","76.54","76.54","1 through 10","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","WELLPOINT [1015]","HB CH WELLPOINT","324.30","77.91","","273.64","94.28","1367.51","138","185.02","324.3","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","246.84","59.3","","720.78","230.14","2010.94","427","208.13","326.55","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","246.84","59.3","","344.45","344.45","344.45","1 through 10","208.13","326.55","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","326.55","78.45","","1120.13","1120.13","1120.13","1 through 10","208.13","326.55","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","326.55","78.45","","456.17","105.33","1284.66","242","208.13","326.55","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","464.71","67.87","1012.10","221","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1967.63","58.3","","293.04","293.04","293.04","11","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","983.89","983.89","983.89","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1957.50","58","","677.18","677.18","677.18","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2109.38","62.5","","46.58","46.58","46.58","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","747.15","747.15","747.15","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","1141.67","481.21","1141.67","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","76.54","76.54","76.54","1 through 10","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","273.64","94.28","1367.51","138","1500.19","2629.46","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","720.78","230.14","2010.94","427","1687.5","2647.69","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2001.38","59.3","","344.45","344.45","344.45","1 through 10","1687.5","2647.69","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","1120.13","1120.13","1120.13","1 through 10","1687.5","2647.69","percent of total billed charges",""
"PLATE BONE 15 HOLE LOCKING STRAIGHT","SUP-ITM-10328916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","456.17","105.33","1284.66","242","1687.5","2647.69","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","AETNA [1001]","HB CH AETNA HMO / PPO","1516.38","58.3","","464.71","67.87","1012.10","221","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1516.38","58.3","","293.04","293.04","293.04","11","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1378.53","53","","983.89","983.89","983.89","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1508.58","58","","677.18","677.18","677.18","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1625.63","62.5","","46.58","46.58","46.58","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1898.73","73","","747.15","747.15","747.15","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1156.14","44.45","","1141.67","481.21","1141.67","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1156.14","44.45","","76.54","76.54","76.54","1 through 10","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.00","1950.75","WELLPOINT [1015]","HB CH WELLPOINT","2026.44","77.91","","273.64","94.28","1367.51","138","1156.14","2026.44","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.00","1950.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1542.39","59.3","","720.78","230.14","2010.94","427","1300.5","2040.48","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.00","1950.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1542.39","59.3","","344.45","344.45","344.45","1 through 10","1300.5","2040.48","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.00","1950.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2040.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1300.5","2040.48","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.00","1950.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2040.48","78.45","","456.17","105.33","1284.66","242","1300.5","2040.48","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","464.71","67.87","1012.10","221","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","293.04","293.04","293.04","11","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","983.89","983.89","983.89","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1456.38","58","","677.18","677.18","677.18","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1569.38","62.5","","46.58","46.58","46.58","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","747.15","747.15","747.15","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","1141.67","481.21","1141.67","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","76.54","76.54","76.54","1 through 10","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","273.64","94.28","1367.51","138","1116.14","1956.32","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","720.78","230.14","2010.94","427","1255.5","1969.88","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1489.02","59.3","","344.45","344.45","344.45","1 through 10","1255.5","1969.88","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1255.5","1969.88","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","456.17","105.33","1284.66","242","1255.5","1969.88","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","AETNA [1001]","HB CH AETNA HMO / PPO","1605.58","58.3","","464.71","67.87","1012.10","221","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1605.58","58.3","","293.04","293.04","293.04","11","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1459.62","53","","983.89","983.89","983.89","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1597.32","58","","677.18","677.18","677.18","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1721.25","62.5","","46.58","46.58","46.58","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2010.42","73","","747.15","747.15","747.15","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.15","44.45","","1141.67","481.21","1141.67","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.15","44.45","","76.54","76.54","76.54","1 through 10","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2754.00","2065.50","WELLPOINT [1015]","HB CH WELLPOINT","2145.64","77.91","","273.64","94.28","1367.51","138","1224.15","2145.64","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2754.00","2065.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1633.12","59.3","","720.78","230.14","2010.94","427","1377","2160.51","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2754.00","2065.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1633.12","59.3","","344.45","344.45","344.45","1 through 10","1377","2160.51","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2754.00","2065.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2160.51","78.45","","1120.13","1120.13","1120.13","1 through 10","1377","2160.51","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2754.00","2065.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2160.51","78.45","","456.17","105.33","1284.66","242","1377","2160.51","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","AETNA [1001]","HB CH AETNA HMO / PPO","5666.76","58.3","","464.71","67.87","1012.10","221","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5666.76","58.3","","293.04","293.04","293.04","11","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5151.60","53","","983.89","983.89","983.89","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5637.60","58","","677.18","677.18","677.18","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6075.00","62.5","","46.58","46.58","46.58","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7095.60","73","","747.15","747.15","747.15","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4320.54","44.45","","1141.67","481.21","1141.67","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4320.54","44.45","","76.54","76.54","76.54","1 through 10","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","9720.00","7290.00","WELLPOINT [1015]","HB CH WELLPOINT","7572.85","77.91","","273.64","94.28","1367.51","138","4320.54","7572.85","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9720.00","7290.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5763.96","59.3","","720.78","230.14","2010.94","427","4860","7625.34","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9720.00","7290.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5763.96","59.3","","344.45","344.45","344.45","1 through 10","4860","7625.34","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9720.00","7290.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7625.34","78.45","","1120.13","1120.13","1120.13","1 through 10","4860","7625.34","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9720.00","7290.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7625.34","78.45","","456.17","105.33","1284.66","242","4860","7625.34","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","AETNA [1001]","HB CH AETNA HMO / PPO","1836.90","58.3","","464.71","67.87","1012.10","221","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1836.90","58.3","","293.04","293.04","293.04","11","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1669.91","53","","983.89","983.89","983.89","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1827.45","58","","677.18","677.18","677.18","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1969.24","62.5","","46.58","46.58","46.58","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2300.07","73","","747.15","747.15","747.15","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1400.52","44.45","","1141.67","481.21","1141.67","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1400.52","44.45","","76.54","76.54","76.54","1 through 10","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.78","2363.08","WELLPOINT [1015]","HB CH WELLPOINT","2454.77","77.91","","273.64","94.28","1367.51","138","1400.52","2454.77","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.78","2363.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","1868.41","59.3","","720.78","230.14","2010.94","427","1575.39","2471.79","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.78","2363.08","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1868.41","59.3","","344.45","344.45","344.45","1 through 10","1575.39","2471.79","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.78","2363.08","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2471.79","78.45","","1120.13","1120.13","1120.13","1 through 10","1575.39","2471.79","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.78","2363.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2471.79","78.45","","456.17","105.33","1284.66","242","1575.39","2471.79","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","AETNA [1001]","HB CH AETNA HMO / PPO","1942.85","58.3","","464.71","67.87","1012.10","221","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1942.85","58.3","","293.04","293.04","293.04","11","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1766.23","53","","983.89","983.89","983.89","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1932.85","58","","677.18","677.18","677.18","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2082.81","62.5","","46.58","46.58","46.58","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2432.73","73","","747.15","747.15","747.15","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1481.30","44.45","","1141.67","481.21","1141.67","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1481.30","44.45","","76.54","76.54","76.54","1 through 10","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.50","2499.37","WELLPOINT [1015]","HB CH WELLPOINT","2596.35","77.91","","273.64","94.28","1367.51","138","1481.3","2596.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.50","2499.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1976.17","59.3","","720.78","230.14","2010.94","427","1666.25","2614.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.50","2499.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1976.17","59.3","","344.45","344.45","344.45","1 through 10","1666.25","2614.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.50","2499.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2614.35","78.45","","1120.13","1120.13","1120.13","1 through 10","1666.25","2614.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10 HOLE 2.0MM THICK ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR RIGHT","SUP-ITM-10286236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.50","2499.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2614.35","78.45","","456.17","105.33","1284.66","242","1666.25","2614.35","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","AETNA [1001]","HB CH AETNA HMO / PPO","2195.00","58.3","","464.71","67.87","1012.10","221","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2195.00","58.3","","293.04","293.04","293.04","11","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1995.45","53","","983.89","983.89","983.89","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2183.70","58","","677.18","677.18","677.18","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2353.13","62.5","","46.58","46.58","46.58","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2748.45","73","","747.15","747.15","747.15","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1673.54","44.45","","1141.67","481.21","1141.67","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1673.54","44.45","","76.54","76.54","76.54","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","WELLPOINT [1015]","HB CH WELLPOINT","2933.31","77.91","","273.64","94.28","1367.51","138","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2232.65","59.3","","720.78","230.14","2010.94","427","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2232.65","59.3","","344.45","344.45","344.45","1 through 10","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2953.64","78.45","","1120.13","1120.13","1120.13","1 through 10","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL LEFT NARROW","SUP-ITM-10237592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2953.64","78.45","","456.17","105.33","1284.66","242","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","AETNA [1001]","HB CH AETNA HMO / PPO","2195.00","58.3","","464.71","67.87","1012.10","221","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2195.00","58.3","","293.04","293.04","293.04","11","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1995.45","53","","983.89","983.89","983.89","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2183.70","58","","677.18","677.18","677.18","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2353.13","62.5","","46.58","46.58","46.58","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2748.45","73","","747.15","747.15","747.15","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1673.54","44.45","","1141.67","481.21","1141.67","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1673.54","44.45","","76.54","76.54","76.54","1 through 10","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.00","2823.75","WELLPOINT [1015]","HB CH WELLPOINT","2933.31","77.91","","273.64","94.28","1367.51","138","1673.54","2933.31","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2232.65","59.3","","720.78","230.14","2010.94","427","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2232.65","59.3","","344.45","344.45","344.45","1 through 10","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2953.64","78.45","","1120.13","1120.13","1120.13","1 through 10","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 10HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT NARROW","SUP-ITM-10237449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.00","2823.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2953.64","78.45","","456.17","105.33","1284.66","242","1882.5","2953.64","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","AETNA [1001]","HB CH AETNA HMO / PPO","2177.51","58.3","","464.71","67.87","1012.10","221","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2177.51","58.3","","293.04","293.04","293.04","11","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1979.55","53","","983.89","983.89","983.89","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2166.30","58","","677.18","677.18","677.18","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2334.38","62.5","","46.58","46.58","46.58","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2726.55","73","","747.15","747.15","747.15","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.21","44.45","","1141.67","481.21","1141.67","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.21","44.45","","76.54","76.54","76.54","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","WELLPOINT [1015]","HB CH WELLPOINT","2909.94","77.91","","273.64","94.28","1367.51","138","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2214.86","59.3","","720.78","230.14","2010.94","427","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2214.86","59.3","","344.45","344.45","344.45","1 through 10","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2930.11","78.45","","1120.13","1120.13","1120.13","1 through 10","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIAL VOL RIGHT","SUP-ITM-10284024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2930.11","78.45","","456.17","105.33","1284.66","242","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","AETNA [1001]","HB CH AETNA HMO / PPO","2177.51","58.3","","464.71","67.87","1012.10","221","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2177.51","58.3","","293.04","293.04","293.04","11","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1979.55","53","","983.89","983.89","983.89","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2166.30","58","","677.18","677.18","677.18","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2334.38","62.5","","46.58","46.58","46.58","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2726.55","73","","747.15","747.15","747.15","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.21","44.45","","1141.67","481.21","1141.67","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.21","44.45","","76.54","76.54","76.54","1 through 10","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","both","","","3735.00","2801.25","WELLPOINT [1015]","HB CH WELLPOINT","2909.94","77.91","","273.64","94.28","1367.51","138","1660.21","2909.94","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2214.86","59.3","","720.78","230.14","2010.94","427","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2214.86","59.3","","344.45","344.45","344.45","1 through 10","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2930.11","78.45","","1120.13","1120.13","1120.13","1 through 10","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2.5X2MM 12 HOLE ADAPTIVE II TRILOCK DISTAL RADIUS VOLAR LEFT LONG","SUP-ITM-10295651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3735.00","2801.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2930.11","78.45","","456.17","105.33","1284.66","242","1867.5","2930.11","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","AETNA [1001]","HB CH AETNA HMO / PPO","693.08","58.3","","464.71","67.87","1012.10","221","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","693.08","58.3","","293.04","293.04","293.04","11","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","630.07","53","","983.89","983.89","983.89","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","689.51","58","","677.18","677.18","677.18","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","743.01","62.5","","46.58","46.58","46.58","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","867.83","73","","747.15","747.15","747.15","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.43","44.45","","1141.67","481.21","1141.67","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.43","44.45","","76.54","76.54","76.54","1 through 10","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","WELLPOINT [1015]","HB CH WELLPOINT","926.20","77.91","","273.64","94.28","1367.51","138","528.43","926.2","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","704.96","59.3","","720.78","230.14","2010.94","427","594.41","932.62","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","704.96","59.3","","344.45","344.45","344.45","1 through 10","594.41","932.62","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","932.62","78.45","","1120.13","1120.13","1120.13","1 through 10","594.41","932.62","percent of total billed charges",""
"PLATE BONE 2MM 12 HOLE STRAIGHT","SUP-ITM-10164592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","932.62","78.45","","456.17","105.33","1284.66","242","594.41","932.62","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","AETNA [1001]","HB CH AETNA HMO / PPO","1504.14","58.3","","464.71","67.87","1012.10","221","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1504.14","58.3","","293.04","293.04","293.04","11","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1367.40","53","","983.89","983.89","983.89","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1496.40","58","","677.18","677.18","677.18","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1612.50","62.5","","46.58","46.58","46.58","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1883.40","73","","747.15","747.15","747.15","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.81","44.45","","1141.67","481.21","1141.67","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.81","44.45","","76.54","76.54","76.54","1 through 10","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","WELLPOINT [1015]","HB CH WELLPOINT","2010.08","77.91","","273.64","94.28","1367.51","138","1146.81","2010.08","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1529.94","59.3","","720.78","230.14","2010.94","427","1290","2024.01","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1529.94","59.3","","344.45","344.45","344.45","1 through 10","1290","2024.01","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1290","2024.01","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","456.17","105.33","1284.66","242","1290","2024.01","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","AETNA [1001]","HB CH AETNA HMO / PPO","905.98","58.3","","464.71","67.87","1012.10","221","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","905.98","58.3","","293.04","293.04","293.04","11","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","823.62","53","","983.89","983.89","983.89","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","901.32","58","","677.18","677.18","677.18","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","971.25","62.5","","46.58","46.58","46.58","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1134.42","73","","747.15","747.15","747.15","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","690.75","44.45","","1141.67","481.21","1141.67","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","690.75","44.45","","76.54","76.54","76.54","1 through 10","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.00","1165.50","WELLPOINT [1015]","HB CH WELLPOINT","1210.72","77.91","","273.64","94.28","1367.51","138","690.75","1210.72","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.00","1165.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","921.52","59.3","","720.78","230.14","2010.94","427","777","1219.11","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.00","1165.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","921.52","59.3","","344.45","344.45","344.45","1 through 10","777","1219.11","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.00","1165.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1219.11","78.45","","1120.13","1120.13","1120.13","1 through 10","777","1219.11","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.00","1165.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1219.11","78.45","","456.17","105.33","1284.66","242","777","1219.11","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","AETNA [1001]","HB CH AETNA HMO / PPO","1320.50","58.3","","464.71","67.87","1012.10","221","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1320.50","58.3","","293.04","293.04","293.04","11","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1200.45","53","","983.89","983.89","983.89","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1313.70","58","","677.18","677.18","677.18","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1415.63","62.5","","46.58","46.58","46.58","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1653.45","73","","747.15","747.15","747.15","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1006.79","44.45","","1141.67","481.21","1141.67","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1006.79","44.45","","76.54","76.54","76.54","1 through 10","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.00","1698.75","WELLPOINT [1015]","HB CH WELLPOINT","1764.66","77.91","","273.64","94.28","1367.51","138","1006.79","1764.66","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1343.15","59.3","","720.78","230.14","2010.94","427","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1343.15","59.3","","344.45","344.45","344.45","1 through 10","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1776.89","78.45","","1120.13","1120.13","1120.13","1 through 10","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 6 HOLE LOCKING CURVED","SUP-ITM-10286758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.00","1698.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1776.89","78.45","","456.17","105.33","1284.66","242","1132.5","1776.89","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","AETNA [1001]","HB CH AETNA HMO / PPO","491.82","58.3","","464.71","67.87","1012.10","221","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","491.82","58.3","","293.04","293.04","293.04","11","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","447.11","53","","983.89","983.89","983.89","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","489.29","58","","677.18","677.18","677.18","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","527.25","62.5","","46.58","46.58","46.58","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","615.83","73","","747.15","747.15","747.15","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.98","44.45","","1141.67","481.21","1141.67","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.98","44.45","","76.54","76.54","76.54","1 through 10","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","WELLPOINT [1015]","HB CH WELLPOINT","657.25","77.91","","273.64","94.28","1367.51","138","374.98","657.25","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","500.25","59.3","","720.78","230.14","2010.94","427","421.8","661.8","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","500.25","59.3","","344.45","344.45","344.45","1 through 10","421.8","661.8","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","661.80","78.45","","1120.13","1120.13","1120.13","1 through 10","421.8","661.8","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","661.80","78.45","","456.17","105.33","1284.66","242","421.8","661.8","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","AETNA [1001]","HB CH AETNA HMO / PPO","394.10","58.3","","464.71","67.87","1012.10","221","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","394.10","58.3","","293.04","293.04","293.04","11","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","358.27","53","","983.89","983.89","983.89","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","392.07","58","","677.18","677.18","677.18","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","422.49","62.5","","46.58","46.58","46.58","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","493.47","73","","747.15","747.15","747.15","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.48","44.45","","1141.67","481.21","1141.67","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.48","44.45","","76.54","76.54","76.54","1 through 10","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.99","506.99","WELLPOINT [1015]","HB CH WELLPOINT","526.66","77.91","","273.64","94.28","1367.51","138","300.48","526.66","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.99","506.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.86","59.3","","720.78","230.14","2010.94","427","338","530.31","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.99","506.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.86","59.3","","344.45","344.45","344.45","1 through 10","338","530.31","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.99","506.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","530.31","78.45","","1120.13","1120.13","1120.13","1 through 10","338","530.31","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.99","506.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","530.31","78.45","","456.17","105.33","1284.66","242","338","530.31","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","AETNA [1001]","HB CH AETNA HMO / PPO","2262.33","58.3","","464.71","67.87","1012.10","221","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2262.33","58.3","","293.04","293.04","293.04","11","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2056.67","53","","983.89","983.89","983.89","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2250.69","58","","677.18","677.18","677.18","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2425.31","62.5","","46.58","46.58","46.58","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","747.15","747.15","747.15","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.88","44.45","","1141.67","481.21","1141.67","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.88","44.45","","76.54","76.54","76.54","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","WELLPOINT [1015]","HB CH WELLPOINT","3023.30","77.91","","273.64","94.28","1367.51","138","1724.88","3023.3","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2301.14","59.3","","720.78","230.14","2010.94","427","1940.25","3044.25","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2301.14","59.3","","344.45","344.45","344.45","1 through 10","1940.25","3044.25","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","1120.13","1120.13","1120.13","1 through 10","1940.25","3044.25","percent of total billed charges",""
"PLATE BONE 7 HOLE POSTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10236276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","456.17","105.33","1284.66","242","1940.25","3044.25","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","AETNA [1001]","HB CH AETNA HMO / PPO","1387.45","58.3","","464.71","67.87","1012.10","221","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1387.45","58.3","","293.04","293.04","293.04","11","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1261.32","53","","983.89","983.89","983.89","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1380.31","58","","677.18","677.18","677.18","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1487.40","62.5","","46.58","46.58","46.58","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1737.28","73","","747.15","747.15","747.15","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.84","44.45","","1141.67","481.21","1141.67","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.84","44.45","","76.54","76.54","76.54","1 through 10","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.84","1784.88","WELLPOINT [1015]","HB CH WELLPOINT","1854.13","77.91","","273.64","94.28","1367.51","138","1057.84","1854.13","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.84","1784.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","1411.25","59.3","","720.78","230.14","2010.94","427","1189.92","1866.98","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.84","1784.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1411.25","59.3","","344.45","344.45","344.45","1 through 10","1189.92","1866.98","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.84","1784.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1866.98","78.45","","1120.13","1120.13","1120.13","1 through 10","1189.92","1866.98","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.84","1784.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1866.98","78.45","","456.17","105.33","1284.66","242","1189.92","1866.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","AETNA [1001]","HB CH AETNA HMO / PPO","474.99","58.3","","464.71","67.87","1012.10","221","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","474.99","58.3","","293.04","293.04","293.04","11","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","431.81","53","","983.89","983.89","983.89","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","472.55","58","","677.18","677.18","677.18","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","509.21","62.5","","46.58","46.58","46.58","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","594.76","73","","747.15","747.15","747.15","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","362.15","44.45","","1141.67","481.21","1141.67","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","362.15","44.45","","76.54","76.54","76.54","1 through 10","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","814.74","611.05","WELLPOINT [1015]","HB CH WELLPOINT","634.76","77.91","","273.64","94.28","1367.51","138","362.15","634.76","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","814.74","611.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","483.14","59.3","","720.78","230.14","2010.94","427","407.37","639.16","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","814.74","611.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","483.14","59.3","","344.45","344.45","344.45","1 through 10","407.37","639.16","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","814.74","611.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","639.16","78.45","","1120.13","1120.13","1120.13","1 through 10","407.37","639.16","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","814.74","611.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","639.16","78.45","","456.17","105.33","1284.66","242","407.37","639.16","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","AETNA [1001]","HB CH AETNA HMO / PPO","492.47","58.3","","464.71","67.87","1012.10","221","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","492.47","58.3","","293.04","293.04","293.04","11","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","447.70","53","","983.89","983.89","983.89","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","489.93","58","","677.18","677.18","677.18","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","527.94","62.5","","46.58","46.58","46.58","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","616.64","73","","747.15","747.15","747.15","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.47","44.45","","1141.67","481.21","1141.67","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.47","44.45","","76.54","76.54","76.54","1 through 10","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","WELLPOINT [1015]","HB CH WELLPOINT","658.11","77.91","","273.64","94.28","1367.51","138","375.47","658.11","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","500.91","59.3","","720.78","230.14","2010.94","427","422.36","662.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","500.91","59.3","","344.45","344.45","344.45","1 through 10","422.36","662.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","662.67","78.45","","1120.13","1120.13","1120.13","1 through 10","422.36","662.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","662.67","78.45","","456.17","105.33","1284.66","242","422.36","662.67","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","AETNA [1001]","HB CH AETNA HMO / PPO","1378.39","58.3","","464.71","67.87","1012.10","221","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1378.39","58.3","","293.04","293.04","293.04","11","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1253.08","53","","983.89","983.89","983.89","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1371.29","58","","677.18","677.18","677.18","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1477.69","62.5","","46.58","46.58","46.58","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1725.94","73","","747.15","747.15","747.15","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1050.93","44.45","","1141.67","481.21","1141.67","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1050.93","44.45","","76.54","76.54","76.54","1 through 10","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2364.30","1773.22","WELLPOINT [1015]","HB CH WELLPOINT","1842.03","77.91","","273.64","94.28","1367.51","138","1050.93","1842.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2364.30","1773.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","1402.03","59.3","","720.78","230.14","2010.94","427","1182.15","1854.79","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2364.30","1773.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1402.03","59.3","","344.45","344.45","344.45","1 through 10","1182.15","1854.79","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2364.30","1773.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1854.79","78.45","","1120.13","1120.13","1120.13","1 through 10","1182.15","1854.79","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2364.30","1773.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1854.79","78.45","","456.17","105.33","1284.66","242","1182.15","1854.79","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","AETNA [1001]","HB CH AETNA HMO / PPO","1398.45","58.3","","464.71","67.87","1012.10","221","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1398.45","58.3","","293.04","293.04","293.04","11","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1271.32","53","","983.89","983.89","983.89","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1391.25","58","","677.18","677.18","677.18","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1499.19","62.5","","46.58","46.58","46.58","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1751.06","73","","747.15","747.15","747.15","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.23","44.45","","1141.67","481.21","1141.67","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.23","44.45","","76.54","76.54","76.54","1 through 10","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.71","1799.03","WELLPOINT [1015]","HB CH WELLPOINT","1868.83","77.91","","273.64","94.28","1367.51","138","1066.23","1868.83","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.71","1799.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1422.44","59.3","","720.78","230.14","2010.94","427","1199.36","1881.79","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.71","1799.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1422.44","59.3","","344.45","344.45","344.45","1 through 10","1199.36","1881.79","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.71","1799.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1881.79","78.45","","1120.13","1120.13","1120.13","1 through 10","1199.36","1881.79","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.71","1799.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1881.79","78.45","","456.17","105.33","1284.66","242","1199.36","1881.79","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","AETNA [1001]","HB CH AETNA HMO / PPO","1466.54","58.3","","464.71","67.87","1012.10","221","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1466.54","58.3","","293.04","293.04","293.04","11","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1333.22","53","","983.89","983.89","983.89","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1458.99","58","","677.18","677.18","677.18","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1572.19","62.5","","46.58","46.58","46.58","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1836.32","73","","747.15","747.15","747.15","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.14","44.45","","1141.67","481.21","1141.67","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.14","44.45","","76.54","76.54","76.54","1 through 10","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","WELLPOINT [1015]","HB CH WELLPOINT","1959.83","77.91","","273.64","94.28","1367.51","138","1118.14","1959.83","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1491.69","59.3","","720.78","230.14","2010.94","427","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1491.69","59.3","","344.45","344.45","344.45","1 through 10","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1973.41","78.45","","1120.13","1120.13","1120.13","1 through 10","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1973.41","78.45","","456.17","105.33","1284.66","242","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","AETNA [1001]","HB CH AETNA HMO / PPO","1422.92","58.3","","464.71","67.87","1012.10","221","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1422.92","58.3","","293.04","293.04","293.04","11","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1293.56","53","","983.89","983.89","983.89","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1415.59","58","","677.18","677.18","677.18","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1525.43","62.5","","46.58","46.58","46.58","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1781.70","73","","747.15","747.15","747.15","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1084.88","44.45","","1141.67","481.21","1141.67","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1084.88","44.45","","76.54","76.54","76.54","1 through 10","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","WELLPOINT [1015]","HB CH WELLPOINT","1901.53","77.91","","273.64","94.28","1367.51","138","1084.88","1901.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","1447.32","59.3","","720.78","230.14","2010.94","427","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1447.32","59.3","","344.45","344.45","344.45","1 through 10","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1914.71","78.45","","1120.13","1120.13","1120.13","1 through 10","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 RIGHT","SUP-ITM-10286301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1914.71","78.45","","456.17","105.33","1284.66","242","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","AETNA [1001]","HB CH AETNA HMO / PPO","1364.15","58.3","","464.71","67.87","1012.10","221","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1364.15","58.3","","293.04","293.04","293.04","11","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.14","53","","983.89","983.89","983.89","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1357.13","58","","677.18","677.18","677.18","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1462.43","62.5","","46.58","46.58","46.58","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1708.11","73","","747.15","747.15","747.15","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.08","44.45","","1141.67","481.21","1141.67","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.08","44.45","","76.54","76.54","76.54","1 through 10","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","WELLPOINT [1015]","HB CH WELLPOINT","1823.00","77.91","","273.64","94.28","1367.51","138","1040.08","1823","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.55","59.3","","720.78","230.14","2010.94","427","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1387.55","59.3","","344.45","344.45","344.45","1 through 10","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1835.64","78.45","","1120.13","1120.13","1120.13","1 through 10","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X100MM 7 HOLE LCP STAINLESS STEEL SUPERIOR RIGHT","SUP-ITM-10076979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.64","78.45","","456.17","105.33","1284.66","242","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","AETNA [1001]","HB CH AETNA HMO / PPO","1329.85","58.3","","2190.90","412.50","9264.59","16","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1323.01","58","","1903.20","1903.20","3826.66","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1425.66","62.5","","2186.25","2186.25","2186.25","32","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.17","73","","5556.60","5556.60","5556.60","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","WELLPOINT [1015]","HB CH WELLPOINT","1777.17","77.91","","1955.15","885.83","3150.40","26","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.66","59.3","","831.03","253.22","2394.88","18","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.48","78.45","","2481.69","1563.74","8149.28","1 through 10","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","AETNA [1001]","HB CH AETNA HMO / PPO","1329.85","58.3","","464.71","67.87","1012.10","221","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1329.85","58.3","","293.04","293.04","293.04","11","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1208.96","53","","983.89","983.89","983.89","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1323.01","58","","677.18","677.18","677.18","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1425.66","62.5","","46.58","46.58","46.58","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.17","73","","747.15","747.15","747.15","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.93","44.45","","1141.67","481.21","1141.67","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.93","44.45","","76.54","76.54","76.54","1 through 10","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","WELLPOINT [1015]","HB CH WELLPOINT","1777.17","77.91","","273.64","94.28","1367.51","138","1013.93","1777.17","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.66","59.3","","720.78","230.14","2010.94","427","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1352.66","59.3","","344.45","344.45","344.45","1 through 10","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1789.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.48","78.45","","456.17","105.33","1284.66","242","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","AETNA [1001]","HB CH AETNA HMO / PPO","1400.39","58.3","","464.71","67.87","1012.10","221","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1400.39","58.3","","293.04","293.04","293.04","11","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1273.08","53","","983.89","983.89","983.89","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1393.18","58","","677.18","677.18","677.18","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1501.28","62.5","","46.58","46.58","46.58","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1753.49","73","","747.15","747.15","747.15","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1067.71","44.45","","1141.67","481.21","1141.67","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1067.71","44.45","","76.54","76.54","76.54","1 through 10","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","WELLPOINT [1015]","HB CH WELLPOINT","1871.43","77.91","","273.64","94.28","1367.51","138","1067.71","1871.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","1424.41","59.3","","720.78","230.14","2010.94","427","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1424.41","59.3","","344.45","344.45","344.45","1 through 10","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1884.40","78.45","","1120.13","1120.13","1120.13","1 through 10","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1884.40","78.45","","456.17","105.33","1284.66","242","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","AETNA [1001]","HB CH AETNA HMO / PPO","1315.62","58.3","","464.71","67.87","1012.10","221","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1315.62","58.3","","293.04","293.04","293.04","11","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1196.01","53","","983.89","983.89","983.89","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1308.85","58","","677.18","677.18","677.18","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1410.39","62.5","","46.58","46.58","46.58","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1647.34","73","","747.15","747.15","747.15","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1003.07","44.45","","1141.67","481.21","1141.67","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1003.07","44.45","","76.54","76.54","76.54","1 through 10","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","WELLPOINT [1015]","HB CH WELLPOINT","1758.14","77.91","","273.64","94.28","1367.51","138","1003.07","1758.14","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","1338.18","59.3","","720.78","230.14","2010.94","427","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1338.18","59.3","","344.45","344.45","344.45","1 through 10","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1770.33","78.45","","1120.13","1120.13","1120.13","1 through 10","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1770.33","78.45","","456.17","105.33","1284.66","242","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","AETNA [1001]","HB CH AETNA HMO / PPO","1446.98","58.3","","464.71","67.87","1012.10","221","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1446.98","58.3","","293.04","293.04","293.04","11","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1315.44","53","","983.89","983.89","983.89","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1439.54","58","","677.18","677.18","677.18","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1551.23","62.5","","46.58","46.58","46.58","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1811.83","73","","747.15","747.15","747.15","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1103.23","44.45","","1141.67","481.21","1141.67","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1103.23","44.45","","76.54","76.54","76.54","1 through 10","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","both","","","2481.96","1861.47","WELLPOINT [1015]","HB CH WELLPOINT","1933.70","77.91","","273.64","94.28","1367.51","138","1103.23","1933.7","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2481.96","1861.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","1471.80","59.3","","720.78","230.14","2010.94","427","1240.98","1947.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2481.96","1861.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1471.80","59.3","","344.45","344.45","344.45","1 through 10","1240.98","1947.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2481.96","1861.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1947.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1240.98","1947.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE SUPERIOR EXTENSION LCP TITANIUM RIGHT","SUP-ITM-10095989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2481.96","1861.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1947.10","78.45","","456.17","105.33","1284.66","242","1240.98","1947.1","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","464.71","67.87","1012.10","221","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","293.04","293.04","293.04","11","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","983.89","983.89","983.89","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","609.00","58","","677.18","677.18","677.18","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","656.25","62.5","","46.58","46.58","46.58","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","747.15","747.15","747.15","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","1141.67","481.21","1141.67","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","76.54","76.54","76.54","1 through 10","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","273.64","94.28","1367.51","138","466.73","818.06","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","720.78","230.14","2010.94","427","525","823.73","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","622.65","59.3","","344.45","344.45","344.45","1 through 10","525","823.73","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","1120.13","1120.13","1120.13","1 through 10","525","823.73","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","456.17","105.33","1284.66","242","525","823.73","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","AETNA [1001]","HB CH AETNA HMO / PPO","799.29","58.3","","464.71","67.87","1012.10","221","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","799.29","58.3","","293.04","293.04","293.04","11","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","726.63","53","","983.89","983.89","983.89","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","795.18","58","","677.18","677.18","677.18","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","856.88","62.5","","46.58","46.58","46.58","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1000.83","73","","747.15","747.15","747.15","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.41","44.45","","1141.67","481.21","1141.67","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.41","44.45","","76.54","76.54","76.54","1 through 10","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.00","1028.25","WELLPOINT [1015]","HB CH WELLPOINT","1068.15","77.91","","273.64","94.28","1367.51","138","609.41","1068.15","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.00","1028.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","813.00","59.3","","720.78","230.14","2010.94","427","685.5","1075.55","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.00","1028.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","813.00","59.3","","344.45","344.45","344.45","1 through 10","685.5","1075.55","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.00","1028.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1075.55","78.45","","1120.13","1120.13","1120.13","1 through 10","685.5","1075.55","percent of total billed charges",""
"PLATE COMPRESSION 1.2MM SCREW HOLE 5 HAND APTUS FIXATION RT PIN","SUP-ITM-10056605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.00","1028.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1075.55","78.45","","456.17","105.33","1284.66","242","685.5","1075.55","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","AETNA [1001]","HB CH AETNA HMO / PPO","2268.02","58.3","","464.71","67.87","1012.10","221","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2268.02","58.3","","293.04","293.04","293.04","11","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2061.83","53","","983.89","983.89","983.89","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2256.35","58","","677.18","677.18","677.18","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2431.41","62.5","","46.58","46.58","46.58","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2839.88","73","","747.15","747.15","747.15","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.22","44.45","","1141.67","481.21","1141.67","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.22","44.45","","76.54","76.54","76.54","1 through 10","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","WELLPOINT [1015]","HB CH WELLPOINT","3030.89","77.91","","273.64","94.28","1367.51","138","1729.22","3030.89","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2306.92","59.3","","720.78","230.14","2010.94","427","1945.13","3051.9","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2306.92","59.3","","344.45","344.45","344.45","1 through 10","1945.13","3051.9","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3051.90","78.45","","1120.13","1120.13","1120.13","1 through 10","1945.13","3051.9","percent of total billed charges",""
"PLATE DOGBONE 20MM SLANTED LEFT","SUP-ITM-10241365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3051.90","78.45","","456.17","105.33","1284.66","242","1945.13","3051.9","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","AETNA [1001]","HB CH AETNA HMO / PPO","2111.02","58.3","","464.71","67.87","1012.10","221","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2111.02","58.3","","293.04","293.04","293.04","11","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1919.11","53","","983.89","983.89","983.89","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2100.16","58","","677.18","677.18","677.18","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2263.10","62.5","","46.58","46.58","46.58","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2643.30","73","","747.15","747.15","747.15","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.52","44.45","","1141.67","481.21","1141.67","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.52","44.45","","76.54","76.54","76.54","1 through 10","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3620.96","2715.72","WELLPOINT [1015]","HB CH WELLPOINT","2821.09","77.91","","273.64","94.28","1367.51","138","1609.52","2821.09","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3620.96","2715.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","2147.23","59.3","","720.78","230.14","2010.94","427","1810.48","2840.64","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3620.96","2715.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2147.23","59.3","","344.45","344.45","344.45","1 through 10","1810.48","2840.64","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3620.96","2715.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2840.64","78.45","","1120.13","1120.13","1120.13","1 through 10","1810.48","2840.64","percent of total billed charges",""
"PLATE DORSAL LISFRANC LARGE LEFT","SUP-ITM-10051918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3620.96","2715.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2840.64","78.45","","456.17","105.33","1284.66","242","1810.48","2840.64","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","AETNA [1001]","HB CH AETNA HMO / PPO","2194.12","58.3","","464.71","67.87","1012.10","221","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2194.12","58.3","","293.04","293.04","293.04","11","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1994.66","53","","983.89","983.89","983.89","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2182.83","58","","677.18","677.18","677.18","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2352.19","62.5","","46.58","46.58","46.58","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2747.36","73","","747.15","747.15","747.15","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1672.88","44.45","","1141.67","481.21","1141.67","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1672.88","44.45","","76.54","76.54","76.54","1 through 10","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","WELLPOINT [1015]","HB CH WELLPOINT","2932.14","77.91","","273.64","94.28","1367.51","138","1672.88","2932.14","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2231.76","59.3","","720.78","230.14","2010.94","427","1881.75","2952.47","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2231.76","59.3","","344.45","344.45","344.45","1 through 10","1881.75","2952.47","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2952.47","78.45","","1120.13","1120.13","1120.13","1 through 10","1881.75","2952.47","percent of total billed charges",""
"PLATE DUAL RAY 1ST AND 2ND LISSFRANC TLEFTSM","SUP-ITM-10241397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2952.47","78.45","","456.17","105.33","1284.66","242","1881.75","2952.47","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","AETNA [1001]","HB CH AETNA HMO / PPO","1414.63","58.3","","464.71","67.87","1012.10","221","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1414.63","58.3","","293.04","293.04","293.04","11","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1286.02","53","","983.89","983.89","983.89","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1407.35","58","","677.18","677.18","677.18","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1516.54","62.5","","46.58","46.58","46.58","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1771.32","73","","747.15","747.15","747.15","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.56","44.45","","1141.67","481.21","1141.67","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.56","44.45","","76.54","76.54","76.54","1 through 10","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","WELLPOINT [1015]","HB CH WELLPOINT","1890.45","77.91","","273.64","94.28","1367.51","138","1078.56","1890.45","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","1438.89","59.3","","720.78","230.14","2010.94","427","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1438.89","59.3","","344.45","344.45","344.45","1 through 10","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1903.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1903.56","78.45","","456.17","105.33","1284.66","242","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","464.71","67.87","1012.10","221","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","293.04","293.04","293.04","11","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","983.89","983.89","983.89","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1506.49","58","","677.18","677.18","677.18","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1623.38","62.5","","46.58","46.58","46.58","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","747.15","747.15","747.15","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","1141.67","481.21","1141.67","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","76.54","76.54","76.54","1 through 10","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","273.64","94.28","1367.51","138","1154.54","2023.63","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","720.78","230.14","2010.94","427","1298.7","2037.66","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1540.26","59.3","","344.45","344.45","344.45","1 through 10","1298.7","2037.66","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1298.7","2037.66","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","456.17","105.33","1284.66","242","1298.7","2037.66","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","AETNA [1001]","HB CH AETNA HMO / PPO","2145.78","58.3","","464.71","67.87","1012.10","221","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2145.78","58.3","","293.04","293.04","293.04","11","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1950.71","53","","983.89","983.89","983.89","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2134.74","58","","677.18","677.18","677.18","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2300.36","62.5","","46.58","46.58","46.58","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2686.82","73","","747.15","747.15","747.15","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1636.02","44.45","","1141.67","481.21","1141.67","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1636.02","44.45","","76.54","76.54","76.54","1 through 10","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","both","","","3680.58","2760.43","WELLPOINT [1015]","HB CH WELLPOINT","2867.54","77.91","","273.64","94.28","1367.51","138","1636.02","2867.54","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3680.58","2760.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2182.58","59.3","","720.78","230.14","2010.94","427","1840.29","2887.42","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3680.58","2760.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2182.58","59.3","","344.45","344.45","344.45","1 through 10","1840.29","2887.42","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3680.58","2760.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2887.42","78.45","","1120.13","1120.13","1120.13","1 through 10","1840.29","2887.42","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3680.58","2760.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2887.42","78.45","","456.17","105.33","1284.66","242","1840.29","2887.42","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","AETNA [1001]","HB CH AETNA HMO / PPO","2196.36","58.3","","464.71","67.87","1012.10","221","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2196.36","58.3","","293.04","293.04","293.04","11","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1996.69","53","","983.89","983.89","983.89","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2185.06","58","","677.18","677.18","677.18","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2354.59","62.5","","46.58","46.58","46.58","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2750.16","73","","747.15","747.15","747.15","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.58","44.45","","1141.67","481.21","1141.67","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.58","44.45","","76.54","76.54","76.54","1 through 10","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.34","2825.50","WELLPOINT [1015]","HB CH WELLPOINT","2935.13","77.91","","273.64","94.28","1367.51","138","1674.58","2935.13","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.34","2825.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2234.03","59.3","","720.78","230.14","2010.94","427","1883.67","2955.48","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.34","2825.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2234.03","59.3","","344.45","344.45","344.45","1 through 10","1883.67","2955.48","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.34","2825.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2955.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1883.67","2955.48","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.34","2825.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2955.48","78.45","","456.17","105.33","1284.66","242","1883.67","2955.48","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","AETNA [1001]","HB CH AETNA HMO / PPO","2231.30","58.3","","464.71","67.87","1012.10","221","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2231.30","58.3","","293.04","293.04","293.04","11","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2028.46","53","","983.89","983.89","983.89","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2219.82","58","","677.18","677.18","677.18","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2392.05","62.5","","46.58","46.58","46.58","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2793.91","73","","747.15","747.15","747.15","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.23","44.45","","1141.67","481.21","1141.67","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.23","44.45","","76.54","76.54","76.54","1 through 10","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","3827.28","2870.46","WELLPOINT [1015]","HB CH WELLPOINT","2981.83","77.91","","273.64","94.28","1367.51","138","1701.23","2981.83","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3827.28","2870.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","2269.58","59.3","","720.78","230.14","2010.94","427","1913.64","3002.5","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3827.28","2870.46","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2269.58","59.3","","344.45","344.45","344.45","1 through 10","1913.64","3002.5","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3827.28","2870.46","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3002.50","78.45","","1120.13","1120.13","1120.13","1 through 10","1913.64","3002.5","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3827.28","2870.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3002.50","78.45","","456.17","105.33","1284.66","242","1913.64","3002.5","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","AETNA [1001]","HB CH AETNA HMO / PPO","1927.37","58.3","","464.71","67.87","1012.10","221","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1927.37","58.3","","293.04","293.04","293.04","11","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1752.15","53","","983.89","983.89","983.89","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1917.45","58","","677.18","677.18","677.18","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2066.22","62.5","","46.58","46.58","46.58","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2413.34","73","","747.15","747.15","747.15","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.49","44.45","","1141.67","481.21","1141.67","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.49","44.45","","76.54","76.54","76.54","1 through 10","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.95","2479.46","WELLPOINT [1015]","HB CH WELLPOINT","2575.67","77.91","","273.64","94.28","1367.51","138","1469.49","2575.67","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.95","2479.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","1960.43","59.3","","720.78","230.14","2010.94","427","1652.98","2593.52","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.95","2479.46","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1960.43","59.3","","344.45","344.45","344.45","1 through 10","1652.98","2593.52","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.95","2479.46","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2593.52","78.45","","1120.13","1120.13","1120.13","1 through 10","1652.98","2593.52","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.95","2479.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2593.52","78.45","","456.17","105.33","1284.66","242","1652.98","2593.52","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","AETNA [1001]","HB CH AETNA HMO / PPO","2026.60","58.3","","464.71","67.87","1012.10","221","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2026.60","58.3","","293.04","293.04","293.04","11","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1842.36","53","","983.89","983.89","983.89","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2016.17","58","","677.18","677.18","677.18","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2172.59","62.5","","46.58","46.58","46.58","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2537.59","73","","747.15","747.15","747.15","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.15","44.45","","1141.67","481.21","1141.67","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.15","44.45","","76.54","76.54","76.54","1 through 10","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3476.15","2607.11","WELLPOINT [1015]","HB CH WELLPOINT","2708.27","77.91","","273.64","94.28","1367.51","138","1545.15","2708.27","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3476.15","2607.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","2061.36","59.3","","720.78","230.14","2010.94","427","1738.08","2727.04","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3476.15","2607.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2061.36","59.3","","344.45","344.45","344.45","1 through 10","1738.08","2727.04","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3476.15","2607.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2727.04","78.45","","1120.13","1120.13","1120.13","1 through 10","1738.08","2727.04","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3476.15","2607.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2727.04","78.45","","456.17","105.33","1284.66","242","1738.08","2727.04","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","AETNA [1001]","HB CH AETNA HMO / PPO","641.39","58.3","","464.71","67.87","1012.10","221","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","641.39","58.3","","293.04","293.04","293.04","11","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","583.08","53","","983.89","983.89","983.89","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","638.09","58","","677.18","677.18","677.18","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","687.60","62.5","","46.58","46.58","46.58","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","803.12","73","","747.15","747.15","747.15","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.02","44.45","","1141.67","481.21","1141.67","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.02","44.45","","76.54","76.54","76.54","1 through 10","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.16","825.12","WELLPOINT [1015]","HB CH WELLPOINT","857.13","77.91","","273.64","94.28","1367.51","138","489.02","857.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.16","825.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","652.39","59.3","","720.78","230.14","2010.94","427","550.08","863.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.16","825.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","652.39","59.3","","344.45","344.45","344.45","1 through 10","550.08","863.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.16","825.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","863.08","78.45","","1120.13","1120.13","1120.13","1 through 10","550.08","863.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.16","825.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","863.08","78.45","","456.17","105.33","1284.66","242","550.08","863.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","AETNA [1001]","HB CH AETNA HMO / PPO","655.94","58.3","","464.71","67.87","1012.10","221","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.94","58.3","","293.04","293.04","293.04","11","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.31","53","","983.89","983.89","983.89","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.57","58","","677.18","677.18","677.18","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.20","62.5","","46.58","46.58","46.58","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.34","73","","747.15","747.15","747.15","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.12","44.45","","1141.67","481.21","1141.67","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.12","44.45","","76.54","76.54","76.54","1 through 10","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","WELLPOINT [1015]","HB CH WELLPOINT","876.58","77.91","","273.64","94.28","1367.51","138","500.12","876.58","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.20","59.3","","720.78","230.14","2010.94","427","562.56","882.66","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.20","59.3","","344.45","344.45","344.45","1 through 10","562.56","882.66","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.66","78.45","","1120.13","1120.13","1120.13","1 through 10","562.56","882.66","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X99MM 5 HOLE DISTAL LCP SS LEFT","SUP-ITM-10091119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.66","78.45","","456.17","105.33","1284.66","242","562.56","882.66","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","AETNA [1001]","HB CH AETNA HMO / PPO","1071.65","58.3","","464.71","67.87","1012.10","221","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1071.65","58.3","","293.04","293.04","293.04","11","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","974.22","53","","983.89","983.89","983.89","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1066.13","58","","677.18","677.18","677.18","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1148.85","62.5","","46.58","46.58","46.58","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1341.86","73","","747.15","747.15","747.15","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","817.06","44.45","","1141.67","481.21","1141.67","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","817.06","44.45","","76.54","76.54","76.54","1 through 10","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","1838.16","1378.62","WELLPOINT [1015]","HB CH WELLPOINT","1432.11","77.91","","273.64","94.28","1367.51","138","817.06","1432.11","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1838.16","1378.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1090.03","59.3","","720.78","230.14","2010.94","427","919.08","1442.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1838.16","1378.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1090.03","59.3","","344.45","344.45","344.45","1 through 10","919.08","1442.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1838.16","1378.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1442.04","78.45","","1120.13","1120.13","1120.13","1 through 10","919.08","1442.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1838.16","1378.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1442.04","78.45","","456.17","105.33","1284.66","242","919.08","1442.04","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","AETNA [1001]","HB CH AETNA HMO / PPO","1421.06","58.3","","464.71","67.87","1012.10","221","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1421.06","58.3","","293.04","293.04","293.04","11","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1291.88","53","","983.89","983.89","983.89","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1413.75","58","","677.18","677.18","677.18","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1523.44","62.5","","46.58","46.58","46.58","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1779.38","73","","747.15","747.15","747.15","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.47","44.45","","1141.67","481.21","1141.67","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.47","44.45","","76.54","76.54","76.54","1 through 10","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","WELLPOINT [1015]","HB CH WELLPOINT","1899.06","77.91","","273.64","94.28","1367.51","138","1083.47","1899.06","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1445.44","59.3","","720.78","230.14","2010.94","427","1218.75","1912.22","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1445.44","59.3","","344.45","344.45","344.45","1 through 10","1218.75","1912.22","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1912.22","78.45","","1120.13","1120.13","1120.13","1 through 10","1218.75","1912.22","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 4 HOLE","SUP-ITM-10241346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1912.22","78.45","","456.17","105.33","1284.66","242","1218.75","1912.22","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","AETNA [1001]","HB CH AETNA HMO / PPO","1717.52","58.3","","464.71","67.87","1012.10","221","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1717.52","58.3","","293.04","293.04","293.04","11","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1561.38","53","","983.89","983.89","983.89","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1708.68","58","","677.18","677.18","677.18","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1841.25","62.5","","46.58","46.58","46.58","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2150.58","73","","747.15","747.15","747.15","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1309.50","44.45","","1141.67","481.21","1141.67","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1309.50","44.45","","76.54","76.54","76.54","1 through 10","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2946.00","2209.50","WELLPOINT [1015]","HB CH WELLPOINT","2295.23","77.91","","273.64","94.28","1367.51","138","1309.5","2295.23","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2946.00","2209.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1746.98","59.3","","720.78","230.14","2010.94","427","1473","2311.14","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2946.00","2209.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1746.98","59.3","","344.45","344.45","344.45","1 through 10","1473","2311.14","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2946.00","2209.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2311.14","78.45","","1120.13","1120.13","1120.13","1 through 10","1473","2311.14","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION TRILOCK TITANIUM ROTATION","SUP-ITM-10170811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2946.00","2209.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2311.14","78.45","","456.17","105.33","1284.66","242","1473","2311.14","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","AETNA [1001]","HB CH AETNA HMO / PPO","484.05","58.3","","464.71","67.87","1012.10","221","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","484.05","58.3","","293.04","293.04","293.04","11","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","440.05","53","","983.89","983.89","983.89","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","481.56","58","","677.18","677.18","677.18","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","518.93","62.5","","46.58","46.58","46.58","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","606.10","73","","747.15","747.15","747.15","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","369.06","44.45","","1141.67","481.21","1141.67","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","369.06","44.45","","76.54","76.54","76.54","1 through 10","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","WELLPOINT [1015]","HB CH WELLPOINT","646.87","77.91","","273.64","94.28","1367.51","138","369.06","646.87","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","492.36","59.3","","720.78","230.14","2010.94","427","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","492.36","59.3","","344.45","344.45","344.45","1 through 10","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","651.35","78.45","","1120.13","1120.13","1120.13","1 through 10","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","651.35","78.45","","456.17","105.33","1284.66","242","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","AETNA [1001]","HB CH AETNA HMO / PPO","569.47","58.3","","464.71","67.87","1012.10","221","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","569.47","58.3","","293.04","293.04","293.04","11","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","517.70","53","","983.89","983.89","983.89","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","566.54","58","","677.18","677.18","677.18","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","610.50","62.5","","46.58","46.58","46.58","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.06","73","","747.15","747.15","747.15","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.19","44.45","","1141.67","481.21","1141.67","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.19","44.45","","76.54","76.54","76.54","1 through 10","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","WELLPOINT [1015]","HB CH WELLPOINT","761.02","77.91","","273.64","94.28","1367.51","138","434.19","761.02","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.24","59.3","","720.78","230.14","2010.94","427","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","579.24","59.3","","344.45","344.45","344.45","1 through 10","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","766.30","78.45","","1120.13","1120.13","1120.13","1 through 10","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","766.30","78.45","","456.17","105.33","1284.66","242","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","AETNA [1001]","HB CH AETNA HMO / PPO","489.23","58.3","","464.71","67.87","1012.10","221","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.23","58.3","","293.04","293.04","293.04","11","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","444.75","53","","983.89","983.89","983.89","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","486.71","58","","677.18","677.18","677.18","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","524.48","62.5","","46.58","46.58","46.58","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","612.59","73","","747.15","747.15","747.15","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.01","44.45","","1141.67","481.21","1141.67","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.01","44.45","","76.54","76.54","76.54","1 through 10","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","WELLPOINT [1015]","HB CH WELLPOINT","653.79","77.91","","273.64","94.28","1367.51","138","373.01","653.79","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","497.62","59.3","","720.78","230.14","2010.94","427","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","497.62","59.3","","344.45","344.45","344.45","1 through 10","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","658.32","78.45","","1120.13","1120.13","1120.13","1 through 10","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.32","78.45","","456.17","105.33","1284.66","242","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","AETNA [1001]","HB CH AETNA HMO / PPO","440.70","58.3","","464.71","67.87","1012.10","221","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","440.70","58.3","","293.04","293.04","293.04","11","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","400.63","53","","983.89","983.89","983.89","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","438.43","58","","677.18","677.18","677.18","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","472.44","62.5","","46.58","46.58","46.58","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","551.81","73","","747.15","747.15","747.15","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.00","44.45","","1141.67","481.21","1141.67","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.00","44.45","","76.54","76.54","76.54","1 through 10","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","WELLPOINT [1015]","HB CH WELLPOINT","588.93","77.91","","273.64","94.28","1367.51","138","336","588.93","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","448.25","59.3","","720.78","230.14","2010.94","427","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","448.25","59.3","","344.45","344.45","344.45","1 through 10","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","593.01","78.45","","1120.13","1120.13","1120.13","1 through 10","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","593.01","78.45","","456.17","105.33","1284.66","242","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","AETNA [1001]","HB CH AETNA HMO / PPO","537.77","58.3","","464.71","67.87","1012.10","221","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","537.77","58.3","","293.04","293.04","293.04","11","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","488.88","53","","983.89","983.89","983.89","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","535.00","58","","677.18","677.18","677.18","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","576.51","62.5","","46.58","46.58","46.58","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","673.36","73","","747.15","747.15","747.15","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.01","44.45","","1141.67","481.21","1141.67","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.01","44.45","","76.54","76.54","76.54","1 through 10","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","WELLPOINT [1015]","HB CH WELLPOINT","718.65","77.91","","273.64","94.28","1367.51","138","410.01","718.65","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","546.99","59.3","","720.78","230.14","2010.94","427","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","546.99","59.3","","344.45","344.45","344.45","1 through 10","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","723.63","78.45","","1120.13","1120.13","1120.13","1 through 10","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","723.63","78.45","","456.17","105.33","1284.66","242","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","AETNA [1001]","HB CH AETNA HMO / PPO","658.78","58.3","","464.71","67.87","1012.10","221","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","658.78","58.3","","293.04","293.04","293.04","11","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","598.89","53","","983.89","983.89","983.89","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","655.39","58","","677.18","677.18","677.18","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","706.24","62.5","","46.58","46.58","46.58","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","824.89","73","","747.15","747.15","747.15","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","502.28","44.45","","1141.67","481.21","1141.67","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","502.28","44.45","","76.54","76.54","76.54","1 through 10","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","both","","","1129.98","847.48","WELLPOINT [1015]","HB CH WELLPOINT","880.37","77.91","","273.64","94.28","1367.51","138","502.28","880.37","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1129.98","847.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","670.08","59.3","","720.78","230.14","2010.94","427","564.99","886.47","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1129.98","847.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","670.08","59.3","","344.45","344.45","344.45","1 through 10","564.99","886.47","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1129.98","847.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","886.47","78.45","","1120.13","1120.13","1120.13","1 through 10","564.99","886.47","percent of total billed charges",""
"PLATE HAND 1.5MM 12 HOLE STRAIGHT","SUP-ITM-10164214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1129.98","847.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","886.47","78.45","","456.17","105.33","1284.66","242","564.99","886.47","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","AETNA [1001]","HB CH AETNA HMO / PPO","280.85","58.3","","464.71","67.87","1012.10","221","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","280.85","58.3","","293.04","293.04","293.04","11","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","255.32","53","","983.89","983.89","983.89","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","279.41","58","","677.18","677.18","677.18","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","301.09","62.5","","46.58","46.58","46.58","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","351.67","73","","747.15","747.15","747.15","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.13","44.45","","1141.67","481.21","1141.67","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.13","44.45","","76.54","76.54","76.54","1 through 10","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","WELLPOINT [1015]","HB CH WELLPOINT","375.32","77.91","","273.64","94.28","1367.51","138","214.13","375.32","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","285.67","59.3","","720.78","230.14","2010.94","427","240.87","377.93","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","285.67","59.3","","344.45","344.45","344.45","1 through 10","240.87","377.93","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","377.93","78.45","","1120.13","1120.13","1120.13","1 through 10","240.87","377.93","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","377.93","78.45","","456.17","105.33","1284.66","242","240.87","377.93","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","AETNA [1001]","HB CH AETNA HMO / PPO","514.47","58.3","","464.71","67.87","1012.10","221","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.47","58.3","","293.04","293.04","293.04","11","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","467.70","53","","983.89","983.89","983.89","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","511.82","58","","677.18","677.18","677.18","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","551.53","62.5","","46.58","46.58","46.58","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.19","73","","747.15","747.15","747.15","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.25","44.45","","1141.67","481.21","1141.67","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.25","44.45","","76.54","76.54","76.54","1 through 10","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.45","661.84","WELLPOINT [1015]","HB CH WELLPOINT","687.52","77.91","","273.64","94.28","1367.51","138","392.25","687.52","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.45","661.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.29","59.3","","720.78","230.14","2010.94","427","441.23","692.28","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.45","661.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.29","59.3","","344.45","344.45","344.45","1 through 10","441.23","692.28","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.45","661.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","692.28","78.45","","1120.13","1120.13","1120.13","1 through 10","441.23","692.28","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.45","661.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.28","78.45","","456.17","105.33","1284.66","242","441.23","692.28","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","AETNA [1001]","HB CH AETNA HMO / PPO","645.19","58.3","","464.71","67.87","1012.10","221","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","645.19","58.3","","293.04","293.04","293.04","11","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","586.54","53","","983.89","983.89","983.89","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","641.87","58","","677.18","677.18","677.18","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","691.67","62.5","","46.58","46.58","46.58","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","807.87","73","","747.15","747.15","747.15","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","491.91","44.45","","1141.67","481.21","1141.67","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","491.91","44.45","","76.54","76.54","76.54","1 through 10","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","WELLPOINT [1015]","HB CH WELLPOINT","862.21","77.91","","273.64","94.28","1367.51","138","491.91","862.21","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","656.26","59.3","","720.78","230.14","2010.94","427","553.34","868.18","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","656.26","59.3","","344.45","344.45","344.45","1 through 10","553.34","868.18","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","868.18","78.45","","1120.13","1120.13","1120.13","1 through 10","553.34","868.18","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","868.18","78.45","","456.17","105.33","1284.66","242","553.34","868.18","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","AETNA [1001]","HB CH AETNA HMO / PPO","478.23","58.3","","464.71","67.87","1012.10","221","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","478.23","58.3","","293.04","293.04","293.04","11","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","434.75","53","","983.89","983.89","983.89","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","475.77","58","","677.18","677.18","677.18","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","512.68","62.5","","46.58","46.58","46.58","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","598.81","73","","747.15","747.15","747.15","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","364.62","44.45","","1141.67","481.21","1141.67","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","364.62","44.45","","76.54","76.54","76.54","1 through 10","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","820.29","615.22","WELLPOINT [1015]","HB CH WELLPOINT","639.09","77.91","","273.64","94.28","1367.51","138","364.62","639.09","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","820.29","615.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","486.43","59.3","","720.78","230.14","2010.94","427","410.15","643.52","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","820.29","615.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","486.43","59.3","","344.45","344.45","344.45","1 through 10","410.15","643.52","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","820.29","615.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","643.52","78.45","","1120.13","1120.13","1120.13","1 through 10","410.15","643.52","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","820.29","615.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","643.52","78.45","","456.17","105.33","1284.66","242","410.15","643.52","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","AETNA [1001]","HB CH AETNA HMO / PPO","477.58","58.3","","464.71","67.87","1012.10","221","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","477.58","58.3","","293.04","293.04","293.04","11","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","434.17","53","","983.89","983.89","983.89","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","475.12","58","","677.18","677.18","677.18","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","511.99","62.5","","46.58","46.58","46.58","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","598.00","73","","747.15","747.15","747.15","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","364.13","44.45","","1141.67","481.21","1141.67","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","364.13","44.45","","76.54","76.54","76.54","1 through 10","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.18","614.38","WELLPOINT [1015]","HB CH WELLPOINT","638.22","77.91","","273.64","94.28","1367.51","138","364.13","638.22","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.18","614.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.77","59.3","","720.78","230.14","2010.94","427","409.59","642.65","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.18","614.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","485.77","59.3","","344.45","344.45","344.45","1 through 10","409.59","642.65","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.18","614.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","642.65","78.45","","1120.13","1120.13","1120.13","1 through 10","409.59","642.65","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.18","614.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","642.65","78.45","","456.17","105.33","1284.66","242","409.59","642.65","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","AETNA [1001]","HB CH AETNA HMO / PPO","688.55","58.3","","464.71","67.87","1012.10","221","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","688.55","58.3","","293.04","293.04","293.04","11","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","625.95","53","","983.89","983.89","983.89","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","685.00","58","","677.18","677.18","677.18","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","738.15","62.5","","46.58","46.58","46.58","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","862.16","73","","747.15","747.15","747.15","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.97","44.45","","1141.67","481.21","1141.67","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.97","44.45","","76.54","76.54","76.54","1 through 10","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","WELLPOINT [1015]","HB CH WELLPOINT","920.15","77.91","","273.64","94.28","1367.51","138","524.97","920.15","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.36","59.3","","720.78","230.14","2010.94","427","590.52","926.53","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","700.36","59.3","","344.45","344.45","344.45","1 through 10","590.52","926.53","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","926.53","78.45","","1120.13","1120.13","1120.13","1 through 10","590.52","926.53","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","926.53","78.45","","456.17","105.33","1284.66","242","590.52","926.53","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","AETNA [1001]","HB CH AETNA HMO / PPO","563.00","58.3","","464.71","67.87","1012.10","221","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","563.00","58.3","","293.04","293.04","293.04","11","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","511.82","53","","983.89","983.89","983.89","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","560.11","58","","677.18","677.18","677.18","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","603.56","62.5","","46.58","46.58","46.58","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","704.96","73","","747.15","747.15","747.15","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","429.25","44.45","","1141.67","481.21","1141.67","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","429.25","44.45","","76.54","76.54","76.54","1 through 10","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","WELLPOINT [1015]","HB CH WELLPOINT","752.38","77.91","","273.64","94.28","1367.51","138","429.25","752.38","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","572.66","59.3","","720.78","230.14","2010.94","427","482.85","757.59","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","572.66","59.3","","344.45","344.45","344.45","1 through 10","482.85","757.59","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","757.59","78.45","","1120.13","1120.13","1120.13","1 through 10","482.85","757.59","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","757.59","78.45","","456.17","105.33","1284.66","242","482.85","757.59","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","AETNA [1001]","HB CH AETNA HMO / PPO","637.42","58.3","","464.71","67.87","1012.10","221","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","637.42","58.3","","293.04","293.04","293.04","11","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","579.48","53","","983.89","983.89","983.89","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","634.14","58","","677.18","677.18","677.18","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","683.34","62.5","","46.58","46.58","46.58","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","798.15","73","","747.15","747.15","747.15","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","485.99","44.45","","1141.67","481.21","1141.67","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","485.99","44.45","","76.54","76.54","76.54","1 through 10","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","WELLPOINT [1015]","HB CH WELLPOINT","851.83","77.91","","273.64","94.28","1367.51","138","485.99","851.83","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","648.36","59.3","","720.78","230.14","2010.94","427","546.68","857.73","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","648.36","59.3","","344.45","344.45","344.45","1 through 10","546.68","857.73","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","857.73","78.45","","1120.13","1120.13","1120.13","1 through 10","546.68","857.73","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","857.73","78.45","","456.17","105.33","1284.66","242","546.68","857.73","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","464.71","67.87","1012.10","221","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","293.04","293.04","293.04","11","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","983.89","983.89","983.89","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","730.80","58","","677.18","677.18","677.18","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","787.50","62.5","","46.58","46.58","46.58","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","747.15","747.15","747.15","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","1141.67","481.21","1141.67","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","76.54","76.54","76.54","1 through 10","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","273.64","94.28","1367.51","138","560.07","981.67","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","720.78","230.14","2010.94","427","630","988.47","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","747.18","59.3","","344.45","344.45","344.45","1 through 10","630","988.47","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","1120.13","1120.13","1120.13","1 through 10","630","988.47","percent of total billed charges",""
"PLATE HAND 4X1.2 1.5MM 8 HOLE APTUS FIXATION OFFSET COMPRESSION","SUP-ITM-10051624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","456.17","105.33","1284.66","242","630","988.47","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","AETNA [1001]","HB CH AETNA HMO / PPO","830.91","58.3","","464.71","67.87","1012.10","221","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.91","58.3","","293.04","293.04","293.04","11","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.38","53","","983.89","983.89","983.89","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","826.64","58","","677.18","677.18","677.18","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","890.78","62.5","","46.58","46.58","46.58","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.43","73","","747.15","747.15","747.15","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.52","44.45","","1141.67","481.21","1141.67","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.52","44.45","","76.54","76.54","76.54","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","WELLPOINT [1015]","HB CH WELLPOINT","1110.40","77.91","","273.64","94.28","1367.51","138","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.17","59.3","","720.78","230.14","2010.94","427","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","845.17","59.3","","344.45","344.45","344.45","1 through 10","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1118.10","78.45","","1120.13","1120.13","1120.13","1 through 10","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1118.10","78.45","","456.17","105.33","1284.66","242","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","AETNA [1001]","HB CH AETNA HMO / PPO","830.91","58.3","","464.71","67.87","1012.10","221","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.91","58.3","","293.04","293.04","293.04","11","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.38","53","","983.89","983.89","983.89","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","826.64","58","","677.18","677.18","677.18","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","890.78","62.5","","46.58","46.58","46.58","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.43","73","","747.15","747.15","747.15","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.52","44.45","","1141.67","481.21","1141.67","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.52","44.45","","76.54","76.54","76.54","1 through 10","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","WELLPOINT [1015]","HB CH WELLPOINT","1110.40","77.91","","273.64","94.28","1367.51","138","633.52","1110.4","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.17","59.3","","720.78","230.14","2010.94","427","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","845.17","59.3","","344.45","344.45","344.45","1 through 10","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1118.10","78.45","","1120.13","1120.13","1120.13","1 through 10","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1118.10","78.45","","456.17","105.33","1284.66","242","712.62","1118.1","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","AETNA [1001]","HB CH AETNA HMO / PPO","1562.82","58.3","","464.71","67.87","1012.10","221","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1562.82","58.3","","293.04","293.04","293.04","11","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1420.74","53","","983.89","983.89","983.89","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1554.78","58","","677.18","677.18","677.18","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1675.41","62.5","","46.58","46.58","46.58","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1956.87","73","","747.15","747.15","747.15","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.55","44.45","","1141.67","481.21","1141.67","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.55","44.45","","76.54","76.54","76.54","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","WELLPOINT [1015]","HB CH WELLPOINT","2088.49","77.91","","273.64","94.28","1367.51","138","1191.55","2088.49","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1589.63","59.3","","720.78","230.14","2010.94","427","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1589.63","59.3","","344.45","344.45","344.45","1 through 10","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2102.97","78.45","","1120.13","1120.13","1120.13","1 through 10","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2102.97","78.45","","456.17","105.33","1284.66","242","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","AETNA [1001]","HB CH AETNA HMO / PPO","2206.78","58.3","","464.71","67.87","1012.10","221","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2206.78","58.3","","293.04","293.04","293.04","11","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2006.17","53","","983.89","983.89","983.89","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2195.43","58","","677.18","677.18","677.18","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2365.76","62.5","","46.58","46.58","46.58","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2763.21","73","","747.15","747.15","747.15","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.53","44.45","","1141.67","481.21","1141.67","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.53","44.45","","76.54","76.54","76.54","1 through 10","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","WELLPOINT [1015]","HB CH WELLPOINT","2949.06","77.91","","273.64","94.28","1367.51","138","1682.53","2949.06","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","2244.64","59.3","","720.78","230.14","2010.94","427","1892.61","2969.51","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2244.64","59.3","","344.45","344.45","344.45","1 through 10","1892.61","2969.51","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2969.51","78.45","","1120.13","1120.13","1120.13","1 through 10","1892.61","2969.51","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2969.51","78.45","","456.17","105.33","1284.66","242","1892.61","2969.51","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","464.71","67.87","1012.10","221","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","293.04","293.04","293.04","11","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","983.89","983.89","983.89","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","677.18","677.18","677.18","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","46.58","46.58","46.58","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","747.15","747.15","747.15","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1141.67","481.21","1141.67","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","76.54","76.54","76.54","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","273.64","94.28","1367.51","138","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","720.78","230.14","2010.94","427","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","344.45","344.45","344.45","1 through 10","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1120.13","1120.13","1120.13","1 through 10","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS LG RIGHT","SUP-ITM-10279101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","456.17","105.33","1284.66","242","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","464.71","67.87","1012.10","221","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","293.04","293.04","293.04","11","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","983.89","983.89","983.89","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2088.00","58","","677.18","677.18","677.18","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2250.00","62.5","","46.58","46.58","46.58","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","747.15","747.15","747.15","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","1141.67","481.21","1141.67","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","76.54","76.54","76.54","1 through 10","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","273.64","94.28","1367.51","138","1600.2","2804.76","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","720.78","230.14","2010.94","427","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2134.80","59.3","","344.45","344.45","344.45","1 through 10","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","1120.13","1120.13","1120.13","1 through 10","1800","2824.2","percent of total billed charges",""
"PLATE LAPIDUS STANDARD RIGHT","SUP-ITM-10279105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","456.17","105.33","1284.66","242","1800","2824.2","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","464.71","67.87","1012.10","221","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","293.04","293.04","293.04","11","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","983.89","983.89","983.89","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","677.18","677.18","677.18","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","46.58","46.58","46.58","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","747.15","747.15","747.15","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1141.67","481.21","1141.67","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","76.54","76.54","76.54","1 through 10","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","273.64","94.28","1367.51","138","933.45","1636.11","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","720.78","230.14","2010.94","427","1050","1647.45","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","344.45","344.45","344.45","1 through 10","1050","1647.45","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1050","1647.45","percent of total billed charges",""
"PLATE LOCKING DISTAL FIBULA TI 5 HOLE LEFT","SUP-ITM-10321920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","456.17","105.33","1284.66","242","1050","1647.45","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","AETNA [1001]","HB CH AETNA HMO / PPO","3523.72","58.3","","464.71","67.87","1012.10","221","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3523.72","58.3","","293.04","293.04","293.04","11","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3203.38","53","","983.89","983.89","983.89","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3505.59","58","","677.18","677.18","677.18","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3777.58","62.5","","46.58","46.58","46.58","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4412.21","73","","747.15","747.15","747.15","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2686.61","44.45","","1141.67","481.21","1141.67","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2686.61","44.45","","76.54","76.54","76.54","1 through 10","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.12","4533.09","WELLPOINT [1015]","HB CH WELLPOINT","4708.97","77.91","","273.64","94.28","1367.51","138","2686.61","4708.97","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.12","4533.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","3584.16","59.3","","720.78","230.14","2010.94","427","3022.06","4741.61","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.12","4533.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3584.16","59.3","","344.45","344.45","344.45","1 through 10","3022.06","4741.61","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.12","4533.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4741.61","78.45","","1120.13","1120.13","1120.13","1 through 10","3022.06","4741.61","percent of total billed charges",""
"PLATE LOCKING MTP RT POLYAXIAL CROSS","SUP-ITM-10190843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.12","4533.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4741.61","78.45","","456.17","105.33","1284.66","242","3022.06","4741.61","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","AETNA [1001]","HB CH AETNA HMO / PPO","841.27","58.3","","464.71","67.87","1012.10","221","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","841.27","58.3","","293.04","293.04","293.04","11","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","764.79","53","","983.89","983.89","983.89","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","836.94","58","","677.18","677.18","677.18","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","901.88","62.5","","46.58","46.58","46.58","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1053.39","73","","747.15","747.15","747.15","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","641.41","44.45","","1141.67","481.21","1141.67","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","641.41","44.45","","76.54","76.54","76.54","1 through 10","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","WELLPOINT [1015]","HB CH WELLPOINT","1124.24","77.91","","273.64","94.28","1367.51","138","641.41","1124.24","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","855.70","59.3","","720.78","230.14","2010.94","427","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","855.70","59.3","","344.45","344.45","344.45","1 through 10","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1132.03","78.45","","1120.13","1120.13","1120.13","1 through 10","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1132.03","78.45","","456.17","105.33","1284.66","242","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","AETNA [1001]","HB CH AETNA HMO / PPO","951.28","58.3","","464.71","67.87","1012.10","221","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","951.28","58.3","","293.04","293.04","293.04","11","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.80","53","","983.89","983.89","983.89","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","946.39","58","","677.18","677.18","677.18","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1019.81","62.5","","46.58","46.58","46.58","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1191.14","73","","747.15","747.15","747.15","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.29","44.45","","1141.67","481.21","1141.67","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.29","44.45","","76.54","76.54","76.54","1 through 10","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","WELLPOINT [1015]","HB CH WELLPOINT","1271.26","77.91","","273.64","94.28","1367.51","138","725.29","1271.26","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.60","59.3","","720.78","230.14","2010.94","427","815.85","1280.07","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","967.60","59.3","","344.45","344.45","344.45","1 through 10","815.85","1280.07","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1280.07","78.45","","1120.13","1120.13","1120.13","1 through 10","815.85","1280.07","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.07","78.45","","456.17","105.33","1284.66","242","815.85","1280.07","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","AETNA [1001]","HB CH AETNA HMO / PPO","2240.54","58.3","","464.71","67.87","1012.10","221","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2240.54","58.3","","293.04","293.04","293.04","11","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2036.86","53","","983.89","983.89","983.89","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2229.02","58","","677.18","677.18","677.18","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2401.96","62.5","","46.58","46.58","46.58","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2805.48","73","","747.15","747.15","747.15","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.27","44.45","","1141.67","481.21","1141.67","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.27","44.45","","76.54","76.54","76.54","1 through 10","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","WELLPOINT [1015]","HB CH WELLPOINT","2994.18","77.91","","273.64","94.28","1367.51","138","1708.27","2994.18","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","2278.98","59.3","","720.78","230.14","2010.94","427","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2278.98","59.3","","344.45","344.45","344.45","1 through 10","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3014.94","78.45","","1120.13","1120.13","1120.13","1 through 10","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 5 DEGREE MED RIGHT","SUP-ITM-10241509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3014.94","78.45","","456.17","105.33","1284.66","242","1921.57","3014.94","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","AETNA [1001]","HB CH AETNA HMO / PPO","1394.57","58.3","","464.71","67.87","1012.10","221","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1394.57","58.3","","293.04","293.04","293.04","11","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.79","53","","983.89","983.89","983.89","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1387.39","58","","677.18","677.18","677.18","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1495.03","62.5","","46.58","46.58","46.58","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1746.20","73","","747.15","747.15","747.15","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1063.27","44.45","","1141.67","481.21","1141.67","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1063.27","44.45","","76.54","76.54","76.54","1 through 10","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","WELLPOINT [1015]","HB CH WELLPOINT","1863.65","77.91","","273.64","94.28","1367.51","138","1063.27","1863.65","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1418.49","59.3","","720.78","230.14","2010.94","427","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1418.49","59.3","","344.45","344.45","344.45","1 through 10","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1876.56","78.45","","1120.13","1120.13","1120.13","1 through 10","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1876.56","78.45","","456.17","105.33","1284.66","242","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","AETNA [1001]","HB CH AETNA HMO / PPO","1215.31","58.3","","464.71","67.87","1012.10","221","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1215.31","58.3","","293.04","293.04","293.04","11","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1104.83","53","","983.89","983.89","983.89","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1209.06","58","","677.18","677.18","677.18","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1302.86","62.5","","46.58","46.58","46.58","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1521.74","73","","747.15","747.15","747.15","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.60","44.45","","1141.67","481.21","1141.67","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.60","44.45","","76.54","76.54","76.54","1 through 10","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","WELLPOINT [1015]","HB CH WELLPOINT","1624.10","77.91","","273.64","94.28","1367.51","138","926.6","1624.1","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","1236.16","59.3","","720.78","230.14","2010.94","427","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1236.16","59.3","","344.45","344.45","344.45","1 through 10","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1635.35","78.45","","1120.13","1120.13","1120.13","1 through 10","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1635.35","78.45","","456.17","105.33","1284.66","242","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","AETNA [1001]","HB CH AETNA HMO / PPO","1358.33","58.3","","464.71","67.87","1012.10","221","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1358.33","58.3","","293.04","293.04","293.04","11","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1234.84","53","","983.89","983.89","983.89","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1351.34","58","","677.18","677.18","677.18","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1456.18","62.5","","46.58","46.58","46.58","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1700.82","73","","747.15","747.15","747.15","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1035.64","44.45","","1141.67","481.21","1141.67","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1035.64","44.45","","76.54","76.54","76.54","1 through 10","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","WELLPOINT [1015]","HB CH WELLPOINT","1815.22","77.91","","273.64","94.28","1367.51","138","1035.64","1815.22","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","1381.62","59.3","","720.78","230.14","2010.94","427","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1381.62","59.3","","344.45","344.45","344.45","1 through 10","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1827.80","78.45","","1120.13","1120.13","1120.13","1 through 10","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1827.80","78.45","","456.17","105.33","1284.66","242","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","AETNA [1001]","HB CH AETNA HMO / PPO","1216.18","58.3","","464.71","67.87","1012.10","221","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1216.18","58.3","","293.04","293.04","293.04","11","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1105.62","53","","983.89","983.89","983.89","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1209.93","58","","677.18","677.18","677.18","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1303.80","62.5","","46.58","46.58","46.58","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1522.84","73","","747.15","747.15","747.15","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","927.26","44.45","","1141.67","481.21","1141.67","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","927.26","44.45","","76.54","76.54","76.54","1 through 10","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","WELLPOINT [1015]","HB CH WELLPOINT","1625.26","77.91","","273.64","94.28","1367.51","138","927.26","1625.26","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1237.05","59.3","","720.78","230.14","2010.94","427","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1237.05","59.3","","344.45","344.45","344.45","1 through 10","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1636.53","78.45","","1120.13","1120.13","1120.13","1 through 10","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1636.53","78.45","","456.17","105.33","1284.66","242","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","AETNA [1001]","HB CH AETNA HMO / PPO","1253.68","58.3","","464.71","67.87","1012.10","221","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1253.68","58.3","","293.04","293.04","293.04","11","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1139.71","53","","983.89","983.89","983.89","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1247.23","58","","677.18","677.18","677.18","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1344.00","62.5","","46.58","46.58","46.58","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1569.79","73","","747.15","747.15","747.15","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.85","44.45","","1141.67","481.21","1141.67","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.85","44.45","","76.54","76.54","76.54","1 through 10","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","WELLPOINT [1015]","HB CH WELLPOINT","1675.38","77.91","","273.64","94.28","1367.51","138","955.85","1675.38","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1275.19","59.3","","720.78","230.14","2010.94","427","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1275.19","59.3","","344.45","344.45","344.45","1 through 10","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1686.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1686.99","78.45","","456.17","105.33","1284.66","242","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","AETNA [1001]","HB CH AETNA HMO / PPO","1292.30","58.3","","464.71","67.87","1012.10","221","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1292.30","58.3","","293.04","293.04","293.04","11","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1174.82","53","","983.89","983.89","983.89","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1285.65","58","","677.18","677.18","677.18","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1385.40","62.5","","46.58","46.58","46.58","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1618.15","73","","747.15","747.15","747.15","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","985.30","44.45","","1141.67","481.21","1141.67","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","985.30","44.45","","76.54","76.54","76.54","1 through 10","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","WELLPOINT [1015]","HB CH WELLPOINT","1726.98","77.91","","273.64","94.28","1367.51","138","985.3","1726.98","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1314.47","59.3","","720.78","230.14","2010.94","427","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1314.47","59.3","","344.45","344.45","344.45","1 through 10","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1738.95","78.45","","1120.13","1120.13","1120.13","1 through 10","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1738.95","78.45","","456.17","105.33","1284.66","242","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","AETNA [1001]","HB CH AETNA HMO / PPO","1329.80","58.3","","464.71","67.87","1012.10","221","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1329.80","58.3","","293.04","293.04","293.04","11","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1208.91","53","","983.89","983.89","983.89","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1322.96","58","","677.18","677.18","677.18","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1425.60","62.5","","46.58","46.58","46.58","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.10","73","","747.15","747.15","747.15","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.89","44.45","","1141.67","481.21","1141.67","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.89","44.45","","76.54","76.54","76.54","1 through 10","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","WELLPOINT [1015]","HB CH WELLPOINT","1777.10","77.91","","273.64","94.28","1367.51","138","1013.89","1777.1","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.61","59.3","","720.78","230.14","2010.94","427","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1352.61","59.3","","344.45","344.45","344.45","1 through 10","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1789.41","78.45","","1120.13","1120.13","1120.13","1 through 10","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.41","78.45","","456.17","105.33","1284.66","242","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","AETNA [1001]","HB CH AETNA HMO / PPO","1351.63","58.3","","464.71","67.87","1012.10","221","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1351.63","58.3","","293.04","293.04","293.04","11","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1228.75","53","","983.89","983.89","983.89","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1344.67","58","","677.18","677.18","677.18","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1449.00","62.5","","46.58","46.58","46.58","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1692.43","73","","747.15","747.15","747.15","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1030.53","44.45","","1141.67","481.21","1141.67","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1030.53","44.45","","76.54","76.54","76.54","1 through 10","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","WELLPOINT [1015]","HB CH WELLPOINT","1806.27","77.91","","273.64","94.28","1367.51","138","1030.53","1806.27","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1374.81","59.3","","720.78","230.14","2010.94","427","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1374.81","59.3","","344.45","344.45","344.45","1 through 10","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1818.78","78.45","","1120.13","1120.13","1120.13","1 through 10","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1818.78","78.45","","456.17","105.33","1284.66","242","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","AETNA [1001]","HB CH AETNA HMO / PPO","1165.25","58.3","","464.71","67.87","1012.10","221","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1165.25","58.3","","293.04","293.04","293.04","11","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1059.32","53","","983.89","983.89","983.89","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1159.26","58","","677.18","677.18","677.18","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1249.20","62.5","","46.58","46.58","46.58","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1459.07","73","","747.15","747.15","747.15","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","888.43","44.45","","1141.67","481.21","1141.67","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","888.43","44.45","","76.54","76.54","76.54","1 through 10","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","WELLPOINT [1015]","HB CH WELLPOINT","1557.20","77.91","","273.64","94.28","1367.51","138","888.43","1557.2","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1185.24","59.3","","720.78","230.14","2010.94","427","999.36","1568","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1185.24","59.3","","344.45","344.45","344.45","1 through 10","999.36","1568","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1568.00","78.45","","1120.13","1120.13","1120.13","1 through 10","999.36","1568","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1568.00","78.45","","456.17","105.33","1284.66","242","999.36","1568","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","AETNA [1001]","HB CH AETNA HMO / PPO","2256.21","58.3","","464.71","67.87","1012.10","221","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2256.21","58.3","","293.04","293.04","293.04","11","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2051.10","53","","983.89","983.89","983.89","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2244.60","58","","677.18","677.18","677.18","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2418.75","62.5","","46.58","46.58","46.58","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2825.10","73","","747.15","747.15","747.15","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.22","44.45","","1141.67","481.21","1141.67","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.22","44.45","","76.54","76.54","76.54","1 through 10","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","WELLPOINT [1015]","HB CH WELLPOINT","3015.12","77.91","","273.64","94.28","1367.51","138","1720.22","3015.12","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.91","59.3","","720.78","230.14","2010.94","427","1935","3036.02","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2294.91","59.3","","344.45","344.45","344.45","1 through 10","1935","3036.02","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3036.02","78.45","","1120.13","1120.13","1120.13","1 through 10","1935","3036.02","percent of total billed charges",""
"PLATE PEG 7 HOLE ULNAR","SUP-ITM-10294394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3036.02","78.45","","456.17","105.33","1284.66","242","1935","3036.02","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","AETNA [1001]","HB CH AETNA HMO / PPO","2259.22","58.3","","464.71","67.87","1012.10","221","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2259.22","58.3","","293.04","293.04","293.04","11","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2053.83","53","","983.89","983.89","983.89","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2247.59","58","","677.18","677.18","677.18","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2421.98","62.5","","46.58","46.58","46.58","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2828.87","73","","747.15","747.15","747.15","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.51","44.45","","1141.67","481.21","1141.67","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.51","44.45","","76.54","76.54","76.54","1 through 10","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","WELLPOINT [1015]","HB CH WELLPOINT","3019.14","77.91","","273.64","94.28","1367.51","138","1722.51","3019.14","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2297.97","59.3","","720.78","230.14","2010.94","427","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2297.97","59.3","","344.45","344.45","344.45","1 through 10","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3040.06","78.45","","1120.13","1120.13","1120.13","1 through 10","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3040.06","78.45","","456.17","105.33","1284.66","242","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","AETNA [1001]","HB CH AETNA HMO / PPO","2057.38","58.3","","464.71","67.87","1012.10","221","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2057.38","58.3","","293.04","293.04","293.04","11","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1870.35","53","","983.89","983.89","983.89","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2046.80","58","","677.18","677.18","677.18","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2205.60","62.5","","46.58","46.58","46.58","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2576.14","73","","747.15","747.15","747.15","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.62","44.45","","1141.67","481.21","1141.67","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.62","44.45","","76.54","76.54","76.54","1 through 10","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","WELLPOINT [1015]","HB CH WELLPOINT","2749.41","77.91","","273.64","94.28","1367.51","138","1568.62","2749.41","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","2092.67","59.3","","720.78","230.14","2010.94","427","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2092.67","59.3","","344.45","344.45","344.45","1 through 10","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2768.47","78.45","","1120.13","1120.13","1120.13","1 through 10","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 19.5X105MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR NARROW LEFT","SUP-ITM-10212950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2768.47","78.45","","456.17","105.33","1284.66","242","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","AETNA [1001]","HB CH AETNA HMO / PPO","1059.47","58.3","","464.71","67.87","1012.10","221","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1059.47","58.3","","293.04","293.04","293.04","11","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","963.16","53","","983.89","983.89","983.89","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1054.02","58","","677.18","677.18","677.18","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1135.80","62.5","","46.58","46.58","46.58","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1326.61","73","","747.15","747.15","747.15","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","807.78","44.45","","1141.67","481.21","1141.67","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","807.78","44.45","","76.54","76.54","76.54","1 through 10","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1817.28","1362.96","WELLPOINT [1015]","HB CH WELLPOINT","1415.84","77.91","","273.64","94.28","1367.51","138","807.78","1415.84","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1817.28","1362.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","1077.65","59.3","","720.78","230.14","2010.94","427","908.64","1425.66","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1817.28","1362.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1077.65","59.3","","344.45","344.45","344.45","1 through 10","908.64","1425.66","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1817.28","1362.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1425.66","78.45","","1120.13","1120.13","1120.13","1 through 10","908.64","1425.66","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1817.28","1362.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1425.66","78.45","","456.17","105.33","1284.66","242","908.64","1425.66","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","AETNA [1001]","HB CH AETNA HMO / PPO","1310.16","58.3","","464.71","67.87","1012.10","221","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1310.16","58.3","","293.04","293.04","293.04","11","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1191.05","53","","983.89","983.89","983.89","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1303.42","58","","677.18","677.18","677.18","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1404.54","62.5","","46.58","46.58","46.58","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1640.51","73","","747.15","747.15","747.15","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.91","44.45","","1141.67","481.21","1141.67","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.91","44.45","","76.54","76.54","76.54","1 through 10","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","WELLPOINT [1015]","HB CH WELLPOINT","1750.85","77.91","","273.64","94.28","1367.51","138","998.91","1750.85","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1332.63","59.3","","720.78","230.14","2010.94","427","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1332.63","59.3","","344.45","344.45","344.45","1 through 10","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1762.98","78.45","","1120.13","1120.13","1120.13","1 through 10","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1762.98","78.45","","456.17","105.33","1284.66","242","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","AETNA [1001]","HB CH AETNA HMO / PPO","1035.97","58.3","","464.71","67.87","1012.10","221","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1035.97","58.3","","293.04","293.04","293.04","11","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","941.79","53","","983.89","983.89","983.89","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1030.64","58","","677.18","677.18","677.18","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1110.60","62.5","","46.58","46.58","46.58","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1297.18","73","","747.15","747.15","747.15","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","789.86","44.45","","1141.67","481.21","1141.67","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","789.86","44.45","","76.54","76.54","76.54","1 through 10","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1776.96","1332.72","WELLPOINT [1015]","HB CH WELLPOINT","1384.43","77.91","","273.64","94.28","1367.51","138","789.86","1384.43","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1776.96","1332.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","1053.74","59.3","","720.78","230.14","2010.94","427","888.48","1394.03","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1776.96","1332.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1053.74","59.3","","344.45","344.45","344.45","1 through 10","888.48","1394.03","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1776.96","1332.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1394.03","78.45","","1120.13","1120.13","1120.13","1 through 10","888.48","1394.03","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION LEFT","SUP-ITM-10095976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1776.96","1332.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1394.03","78.45","","456.17","105.33","1284.66","242","888.48","1394.03","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","AETNA [1001]","HB CH AETNA HMO / PPO","1359.13","58.3","","464.71","67.87","1012.10","221","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1359.13","58.3","","293.04","293.04","293.04","11","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1235.57","53","","983.89","983.89","983.89","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1352.14","58","","677.18","677.18","677.18","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1457.04","62.5","","46.58","46.58","46.58","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1701.83","73","","747.15","747.15","747.15","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1036.25","44.45","","1141.67","481.21","1141.67","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1036.25","44.45","","76.54","76.54","76.54","1 through 10","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","WELLPOINT [1015]","HB CH WELLPOINT","1816.29","77.91","","273.64","94.28","1367.51","138","1036.25","1816.29","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1382.44","59.3","","720.78","230.14","2010.94","427","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1382.44","59.3","","344.45","344.45","344.45","1 through 10","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1828.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1828.88","78.45","","456.17","105.33","1284.66","242","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","AETNA [1001]","HB CH AETNA HMO / PPO","956.63","58.3","","464.71","67.87","1012.10","221","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","956.63","58.3","","293.04","293.04","293.04","11","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","869.67","53","","983.89","983.89","983.89","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","951.71","58","","677.18","677.18","677.18","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1025.55","62.5","","46.58","46.58","46.58","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1197.84","73","","747.15","747.15","747.15","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","729.37","44.45","","1141.67","481.21","1141.67","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","729.37","44.45","","76.54","76.54","76.54","1 through 10","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","WELLPOINT [1015]","HB CH WELLPOINT","1278.41","77.91","","273.64","94.28","1367.51","138","729.37","1278.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","973.04","59.3","","720.78","230.14","2010.94","427","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","973.04","59.3","","344.45","344.45","344.45","1 through 10","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1287.27","78.45","","1120.13","1120.13","1120.13","1 through 10","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1287.27","78.45","","456.17","105.33","1284.66","242","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","AETNA [1001]","HB CH AETNA HMO / PPO","1052.90","58.3","","464.71","67.87","1012.10","221","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1052.90","58.3","","293.04","293.04","293.04","11","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","957.18","53","","983.89","983.89","983.89","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1047.48","58","","677.18","677.18","677.18","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1128.75","62.5","","46.58","46.58","46.58","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1318.38","73","","747.15","747.15","747.15","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.77","44.45","","1141.67","481.21","1141.67","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.77","44.45","","76.54","76.54","76.54","1 through 10","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","both","","","1806.00","1354.50","WELLPOINT [1015]","HB CH WELLPOINT","1407.05","77.91","","273.64","94.28","1367.51","138","802.77","1407.05","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1806.00","1354.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1070.96","59.3","","720.78","230.14","2010.94","427","903","1416.81","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1806.00","1354.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1070.96","59.3","","344.45","344.45","344.45","1 through 10","903","1416.81","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1806.00","1354.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1416.81","78.45","","1120.13","1120.13","1120.13","1 through 10","903","1416.81","percent of total billed charges",""
"PLATE RADIUS 2.4X43MM 3 HOLE HEAD SHAFT 20DEG LCP TITANIUM DISTAL PLUS SHAPE","SUP-ITM-10013603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1806.00","1354.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1416.81","78.45","","456.17","105.33","1284.66","242","903","1416.81","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","AETNA [1001]","HB CH AETNA HMO / PPO","1031.84","58.3","","464.71","67.87","1012.10","221","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.84","58.3","","293.04","293.04","293.04","11","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.04","53","","983.89","983.89","983.89","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.53","58","","677.18","677.18","677.18","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.18","62.5","","46.58","46.58","46.58","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.01","73","","747.15","747.15","747.15","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.71","44.45","","1141.67","481.21","1141.67","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.71","44.45","","76.54","76.54","76.54","1 through 10","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.88","1327.41","WELLPOINT [1015]","HB CH WELLPOINT","1378.91","77.91","","273.64","94.28","1367.51","138","786.71","1378.91","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.88","1327.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.54","59.3","","720.78","230.14","2010.94","427","884.94","1388.47","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.88","1327.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1049.54","59.3","","344.45","344.45","344.45","1 through 10","884.94","1388.47","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.88","1327.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1388.47","78.45","","1120.13","1120.13","1120.13","1 through 10","884.94","1388.47","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.88","1327.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.47","78.45","","456.17","105.33","1284.66","242","884.94","1388.47","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","AETNA [1001]","HB CH AETNA HMO / PPO","1031.09","58.3","","464.71","67.87","1012.10","221","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.09","58.3","","293.04","293.04","293.04","11","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","937.35","53","","983.89","983.89","983.89","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1025.78","58","","677.18","677.18","677.18","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1105.37","62.5","","46.58","46.58","46.58","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1291.07","73","","747.15","747.15","747.15","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.14","44.45","","1141.67","481.21","1141.67","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.14","44.45","","76.54","76.54","76.54","1 through 10","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","WELLPOINT [1015]","HB CH WELLPOINT","1377.91","77.91","","273.64","94.28","1367.51","138","786.14","1377.91","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1048.77","59.3","","720.78","230.14","2010.94","427","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1048.77","59.3","","344.45","344.45","344.45","1 through 10","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1387.46","78.45","","1120.13","1120.13","1120.13","1 through 10","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1387.46","78.45","","456.17","105.33","1284.66","242","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","AETNA [1001]","HB CH AETNA HMO / PPO","1296.57","58.3","","464.71","67.87","1012.10","221","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1296.57","58.3","","293.04","293.04","293.04","11","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1178.70","53","","983.89","983.89","983.89","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1289.90","58","","677.18","677.18","677.18","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1389.98","62.5","","46.58","46.58","46.58","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1623.49","73","","747.15","747.15","747.15","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","988.55","44.45","","1141.67","481.21","1141.67","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","988.55","44.45","","76.54","76.54","76.54","1 through 10","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2223.96","1667.97","WELLPOINT [1015]","HB CH WELLPOINT","1732.69","77.91","","273.64","94.28","1367.51","138","988.55","1732.69","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2223.96","1667.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1318.81","59.3","","720.78","230.14","2010.94","427","1111.98","1744.7","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2223.96","1667.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1318.81","59.3","","344.45","344.45","344.45","1 through 10","1111.98","1744.7","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2223.96","1667.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1744.70","78.45","","1120.13","1120.13","1120.13","1 through 10","1111.98","1744.7","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2223.96","1667.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1744.70","78.45","","456.17","105.33","1284.66","242","1111.98","1744.7","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","AETNA [1001]","HB CH AETNA HMO / PPO","2003.01","58.3","","464.71","67.87","1012.10","221","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2003.01","58.3","","293.04","293.04","293.04","11","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1820.92","53","","983.89","983.89","983.89","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1992.71","58","","677.18","677.18","677.18","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2147.31","62.5","","46.58","46.58","46.58","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2508.06","73","","747.15","747.15","747.15","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1527.17","44.45","","1141.67","481.21","1141.67","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1527.17","44.45","","76.54","76.54","76.54","1 through 10","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.70","2576.77","WELLPOINT [1015]","HB CH WELLPOINT","2676.75","77.91","","273.64","94.28","1367.51","138","1527.17","2676.75","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.70","2576.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2037.37","59.3","","720.78","230.14","2010.94","427","1717.85","2695.31","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.70","2576.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2037.37","59.3","","344.45","344.45","344.45","1 through 10","1717.85","2695.31","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.70","2576.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2695.31","78.45","","1120.13","1120.13","1120.13","1 through 10","1717.85","2695.31","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.70","2576.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2695.31","78.45","","456.17","105.33","1284.66","242","1717.85","2695.31","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","AETNA [1001]","HB CH AETNA HMO / PPO","2198.46","58.3","","464.71","67.87","1012.10","221","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2198.46","58.3","","293.04","293.04","293.04","11","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1998.60","53","","983.89","983.89","983.89","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2187.15","58","","677.18","677.18","677.18","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2356.84","62.5","","46.58","46.58","46.58","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2752.79","73","","747.15","747.15","747.15","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1676.19","44.45","","1141.67","481.21","1141.67","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1676.19","44.45","","76.54","76.54","76.54","1 through 10","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.95","2828.21","WELLPOINT [1015]","HB CH WELLPOINT","2937.95","77.91","","273.64","94.28","1367.51","138","1676.19","2937.95","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.95","2828.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","2236.17","59.3","","720.78","230.14","2010.94","427","1885.48","2958.31","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.95","2828.21","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2236.17","59.3","","344.45","344.45","344.45","1 through 10","1885.48","2958.31","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.95","2828.21","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2958.31","78.45","","1120.13","1120.13","1120.13","1 through 10","1885.48","2958.31","percent of total billed charges",""
"PLATE STRAIGHT 40MM 6 HOLE","SUP-ITM-10082664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.95","2828.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2958.31","78.45","","456.17","105.33","1284.66","242","1885.48","2958.31","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","AETNA [1001]","HB CH AETNA HMO / PPO","1908.38","58.3","","464.71","67.87","1012.10","221","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1908.38","58.3","","293.04","293.04","293.04","11","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1734.89","53","","983.89","983.89","983.89","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1898.56","58","","677.18","677.18","677.18","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2045.86","62.5","","46.58","46.58","46.58","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2389.57","73","","747.15","747.15","747.15","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.02","44.45","","1141.67","481.21","1141.67","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.02","44.45","","76.54","76.54","76.54","1 through 10","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","WELLPOINT [1015]","HB CH WELLPOINT","2550.29","77.91","","273.64","94.28","1367.51","138","1455.02","2550.29","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1941.11","59.3","","720.78","230.14","2010.94","427","1636.69","2567.97","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1941.11","59.3","","344.45","344.45","344.45","1 through 10","1636.69","2567.97","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2567.97","78.45","","1120.13","1120.13","1120.13","1 through 10","1636.69","2567.97","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X142MM 6 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL LEFT","SUP-ITM-10124890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2567.97","78.45","","456.17","105.33","1284.66","242","1636.69","2567.97","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","AETNA [1001]","HB CH AETNA HMO / PPO","2182.49","58.3","","1530.90","1160.93","1884.08","89","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1984.08","53","","5253.92","5253.92","5253.92","1 through 10","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2171.26","58","","12181.47","12181.47","12181.47","1 through 10","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2339.72","62.5","","1350.68","1350.68","1350.68","1 through 10","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1664.01","44.45","","1910.74","891.94","1910.74","1 through 10","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","3743.55","2807.66","WELLPOINT [1015]","HB CH WELLPOINT","2916.60","77.91","","1829.79","1561.50","2617.12","88","1664.01","2916.6","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3743.55","2807.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2219.93","59.3","","1359.46","1201.30","1689.00","61","1871.78","2936.81","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3743.55","2807.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2219.93","59.3","","1718.92","1718.92","1718.92","1 through 10","1871.78","2936.81","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3743.55","2807.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2936.81","78.45","","1910.74","1019.06","2344.84","74","1871.78","2936.81","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","AETNA [1001]","HB CH AETNA HMO / PPO","1843.67","58.3","","464.71","67.87","1012.10","221","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1843.67","58.3","","293.04","293.04","293.04","11","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1676.07","53","","983.89","983.89","983.89","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1834.19","58","","677.18","677.18","677.18","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1976.49","62.5","","46.58","46.58","46.58","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2308.54","73","","747.15","747.15","747.15","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1405.68","44.45","","1141.67","481.21","1141.67","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1405.68","44.45","","76.54","76.54","76.54","1 through 10","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.39","2371.79","WELLPOINT [1015]","HB CH WELLPOINT","2463.82","77.91","","273.64","94.28","1367.51","138","1405.68","2463.82","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.39","2371.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","1875.30","59.3","","720.78","230.14","2010.94","427","1581.2","2480.89","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.39","2371.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1875.30","59.3","","344.45","344.45","344.45","1 through 10","1581.2","2480.89","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.39","2371.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2480.89","78.45","","1120.13","1120.13","1120.13","1 through 10","1581.2","2480.89","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.39","2371.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2480.89","78.45","","456.17","105.33","1284.66","242","1581.2","2480.89","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","AETNA [1001]","HB CH AETNA HMO / PPO","1864.38","58.3","","464.71","67.87","1012.10","221","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1864.38","58.3","","293.04","293.04","293.04","11","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1694.89","53","","983.89","983.89","983.89","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1854.79","58","","677.18","677.18","677.18","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1998.69","62.5","","46.58","46.58","46.58","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2334.47","73","","747.15","747.15","747.15","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1421.47","44.45","","1141.67","481.21","1141.67","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1421.47","44.45","","76.54","76.54","76.54","1 through 10","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3197.91","2398.43","WELLPOINT [1015]","HB CH WELLPOINT","2491.49","77.91","","273.64","94.28","1367.51","138","1421.47","2491.49","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3197.91","2398.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","1896.36","59.3","","720.78","230.14","2010.94","427","1598.96","2508.76","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3197.91","2398.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1896.36","59.3","","344.45","344.45","344.45","1 through 10","1598.96","2508.76","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3197.91","2398.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2508.76","78.45","","1120.13","1120.13","1120.13","1 through 10","1598.96","2508.76","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3197.91","2398.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2508.76","78.45","","456.17","105.33","1284.66","242","1598.96","2508.76","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","AETNA [1001]","HB CH AETNA HMO / PPO","1888.97","58.3","","464.71","67.87","1012.10","221","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1888.97","58.3","","293.04","293.04","293.04","11","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1717.25","53","","983.89","983.89","983.89","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1879.25","58","","677.18","677.18","677.18","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2025.06","62.5","","46.58","46.58","46.58","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2365.27","73","","747.15","747.15","747.15","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1440.22","44.45","","1141.67","481.21","1141.67","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1440.22","44.45","","76.54","76.54","76.54","1 through 10","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","WELLPOINT [1015]","HB CH WELLPOINT","2524.35","77.91","","273.64","94.28","1367.51","138","1440.22","2524.35","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1921.37","59.3","","720.78","230.14","2010.94","427","1620.05","2541.85","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1921.37","59.3","","344.45","344.45","344.45","1 through 10","1620.05","2541.85","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2541.85","78.45","","1120.13","1120.13","1120.13","1 through 10","1620.05","2541.85","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2541.85","78.45","","456.17","105.33","1284.66","242","1620.05","2541.85","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","AETNA [1001]","HB CH AETNA HMO / PPO","2262.33","58.3","","464.71","67.87","1012.10","221","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2262.33","58.3","","293.04","293.04","293.04","11","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2056.67","53","","983.89","983.89","983.89","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2250.69","58","","677.18","677.18","677.18","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2425.31","62.5","","46.58","46.58","46.58","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","747.15","747.15","747.15","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.88","44.45","","1141.67","481.21","1141.67","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.88","44.45","","76.54","76.54","76.54","1 through 10","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","WELLPOINT [1015]","HB CH WELLPOINT","3023.30","77.91","","273.64","94.28","1367.51","138","1724.88","3023.3","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2301.14","59.3","","720.78","230.14","2010.94","427","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2301.14","59.3","","344.45","344.45","344.45","1 through 10","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","1120.13","1120.13","1120.13","1 through 10","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 7-HOLE ANATOMICAL RIGHT","SUP-ITM-10241317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","456.17","105.33","1284.66","242","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","AETNA [1001]","HB CH AETNA HMO / PPO","1752.43","58.3","","464.71","67.87","1012.10","221","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.43","58.3","","293.04","293.04","293.04","11","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.12","53","","983.89","983.89","983.89","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1743.41","58","","677.18","677.18","677.18","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1878.68","62.5","","46.58","46.58","46.58","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.29","73","","747.15","747.15","747.15","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.11","44.45","","1141.67","481.21","1141.67","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.11","44.45","","76.54","76.54","76.54","1 through 10","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","WELLPOINT [1015]","HB CH WELLPOINT","2341.88","77.91","","273.64","94.28","1367.51","138","1336.11","2341.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.49","59.3","","720.78","230.14","2010.94","427","1502.94","2358.11","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1782.49","59.3","","344.45","344.45","344.45","1 through 10","1502.94","2358.11","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2358.11","78.45","","1120.13","1120.13","1120.13","1 through 10","1502.94","2358.11","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.11","78.45","","456.17","105.33","1284.66","242","1502.94","2358.11","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","AETNA [1001]","HB CH AETNA HMO / PPO","1897.58","58.3","","464.71","67.87","1012.10","221","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1897.58","58.3","","293.04","293.04","293.04","11","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.07","53","","983.89","983.89","983.89","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1887.81","58","","677.18","677.18","677.18","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2034.28","62.5","","46.58","46.58","46.58","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2376.04","73","","747.15","747.15","747.15","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.78","44.45","","1141.67","481.21","1141.67","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.78","44.45","","76.54","76.54","76.54","1 through 10","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3254.85","2441.14","WELLPOINT [1015]","HB CH WELLPOINT","2535.85","77.91","","273.64","94.28","1367.51","138","1446.78","2535.85","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3254.85","2441.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.13","59.3","","720.78","230.14","2010.94","427","1627.43","2553.43","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3254.85","2441.14","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1930.13","59.3","","344.45","344.45","344.45","1 through 10","1627.43","2553.43","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3254.85","2441.14","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2553.43","78.45","","1120.13","1120.13","1120.13","1 through 10","1627.43","2553.43","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3254.85","2441.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2553.43","78.45","","456.17","105.33","1284.66","242","1627.43","2553.43","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","AETNA [1001]","HB CH AETNA HMO / PPO","2044.44","58.3","","464.71","67.87","1012.10","221","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2044.44","58.3","","293.04","293.04","293.04","11","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1858.58","53","","983.89","983.89","983.89","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2033.92","58","","677.18","677.18","677.18","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2191.73","62.5","","46.58","46.58","46.58","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2559.93","73","","747.15","747.15","747.15","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1558.75","44.45","","1141.67","481.21","1141.67","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1558.75","44.45","","76.54","76.54","76.54","1 through 10","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.76","2630.07","WELLPOINT [1015]","HB CH WELLPOINT","2732.12","77.91","","273.64","94.28","1367.51","138","1558.75","2732.12","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.76","2630.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","2079.51","59.3","","720.78","230.14","2010.94","427","1753.38","2751.05","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.76","2630.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2079.51","59.3","","344.45","344.45","344.45","1 through 10","1753.38","2751.05","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.76","2630.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2751.05","78.45","","1120.13","1120.13","1120.13","1 through 10","1753.38","2751.05","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.76","2630.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2751.05","78.45","","456.17","105.33","1284.66","242","1753.38","2751.05","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","AETNA [1001]","HB CH AETNA HMO / PPO","2263.50","58.3","","464.71","67.87","1012.10","221","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2263.50","58.3","","293.04","293.04","293.04","11","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2057.73","53","","983.89","983.89","983.89","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2251.85","58","","677.18","677.18","677.18","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2426.56","62.5","","46.58","46.58","46.58","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2834.23","73","","747.15","747.15","747.15","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.77","44.45","","1141.67","481.21","1141.67","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.77","44.45","","76.54","76.54","76.54","1 through 10","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3882.50","2911.87","WELLPOINT [1015]","HB CH WELLPOINT","3024.86","77.91","","273.64","94.28","1367.51","138","1725.77","3024.86","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3882.50","2911.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2302.32","59.3","","720.78","230.14","2010.94","427","1941.25","3045.82","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3882.50","2911.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2302.32","59.3","","344.45","344.45","344.45","1 through 10","1941.25","3045.82","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3882.50","2911.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3045.82","78.45","","1120.13","1120.13","1120.13","1 through 10","1941.25","3045.82","percent of total billed charges",""
"PLATE TRILOCK 2.5 ULNA SHORTENING PLATE","SUP-ITM-10238947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3882.50","2911.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3045.82","78.45","","456.17","105.33","1284.66","242","1941.25","3045.82","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","AETNA [1001]","HB CH AETNA HMO / PPO","1562.82","58.3","","464.71","67.87","1012.10","221","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1562.82","58.3","","293.04","293.04","293.04","11","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1420.74","53","","983.89","983.89","983.89","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1554.78","58","","677.18","677.18","677.18","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1675.41","62.5","","46.58","46.58","46.58","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1956.87","73","","747.15","747.15","747.15","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.55","44.45","","1141.67","481.21","1141.67","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.55","44.45","","76.54","76.54","76.54","1 through 10","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","WELLPOINT [1015]","HB CH WELLPOINT","2088.49","77.91","","273.64","94.28","1367.51","138","1191.55","2088.49","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1589.63","59.3","","720.78","230.14","2010.94","427","1340.33","2102.97","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1589.63","59.3","","344.45","344.45","344.45","1 through 10","1340.33","2102.97","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2102.97","78.45","","1120.13","1120.13","1120.13","1 through 10","1340.33","2102.97","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2102.97","78.45","","456.17","105.33","1284.66","242","1340.33","2102.97","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","AETNA [1001]","HB CH AETNA HMO / PPO","752.07","58.3","","464.71","67.87","1012.10","221","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","752.07","58.3","","293.04","293.04","293.04","11","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","683.70","53","","983.89","983.89","983.89","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","748.20","58","","677.18","677.18","677.18","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","806.25","62.5","","46.58","46.58","46.58","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","941.70","73","","747.15","747.15","747.15","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.41","44.45","","1141.67","481.21","1141.67","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.41","44.45","","76.54","76.54","76.54","1 through 10","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","both","","","1290.00","967.50","WELLPOINT [1015]","HB CH WELLPOINT","1005.04","77.91","","273.64","94.28","1367.51","138","573.41","1005.04","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1290.00","967.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","764.97","59.3","","720.78","230.14","2010.94","427","645","1012.01","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1290.00","967.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","764.97","59.3","","344.45","344.45","344.45","1 through 10","645","1012.01","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1290.00","967.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1012.01","78.45","","1120.13","1120.13","1120.13","1 through 10","645","1012.01","percent of total billed charges",""
"PLATE WIRE 30MM 3 HOLE WRIST FIXATION SYSTEM","SUP-ITM-10090908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1290.00","967.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1012.01","78.45","","456.17","105.33","1284.66","242","645","1012.01","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","251.00","188.25","AETNA [1001]","HB CH AETNA HMO / PPO","146.33","58.3","","138.35","138.35","138.35","14","24.41","238.45","percent of total billed charges",""
"Platelet Antibody ID","PX-30000780","CDM","86022","CPT","0302","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","154.53","154.53","154.53","1 through 10","18.94","162.39","percent of total billed charges",""
"Platelet Antibody ID Assoc","PX-30000782","CDM","86023","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","63.33","63.33","106.86","1 through 10","12.85","112.18","percent of total billed charges",""
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","outpatient","","","3050.00","2287.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2392.73","78.45","","2280.26","2280.26","2280.26","1 through 10","1047.44","2392.73","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","13","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","169","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","351.32","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","197.14","981.49","other","Tricare OPPS"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.81","12","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","336.52","363.42","12","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","896.00","672.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","531.33","59.3","","510.41","510.41","510.41","12","191.73","702.91","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","896.00","672.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","702.91","78.45","","669.62","396.83","714.04","20","191.73","702.91","percent of total billed charges",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","","","","inpatient","","","28857.79","21643.34","MEDICARE [2001]","HB NWH MEDICARE","9422.36","","Case rate ($9,422.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,803.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,945.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,596.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,767.50. The transfer operating threshold is the transfer adjustment factor * $8,803.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.87. The transfer capital threshold is the transfer adjustment factor * $654.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9599.57","9599.57","9599.57","1 through 10","8398.09","9928.556","other","Inpatient DRG"
"Pleural Effusion With Cc","187","MS-DRG","","","","","","","","inpatient","","","28857.79","21643.34","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8398.09","","Case rate ($8,569.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,803.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,945.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,596.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,914.62. The transfer operating threshold is the transfer adjustment factor * $8,803.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.87. The transfer capital threshold is the transfer adjustment factor * $654.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8572.02","8572.02","8572.02","1 through 10","8398.09","9928.556","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","24715.14","18536.35","MEDICARE [2001]","HB NWH MEDICARE","14846.59","","Case rate ($14,846.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,870.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,013.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,973.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,814.72. The transfer operating threshold is the transfer adjustment factor * $13,870.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,031.86. The transfer capital threshold is the transfer adjustment factor * $1,031.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15079.79","15079.79","15106.89","1 through 10","13232.68","15998","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","24715.14","18536.35","MOLINA [1014]","HB NWH MEDICARE","14846.59","","Case rate ($14,846.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,870.97, add-ons for qualifying new technology services are included. If operating cost exceeds $59,013.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,973.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,814.72. The transfer operating threshold is the transfer adjustment factor * $13,870.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,031.86. The transfer capital threshold is the transfer adjustment factor * $1,031.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27252.22","27252.22","27252.22","1 through 10","13232.68","15998","other","Inpatient DRG"
"Pleural Effusion Without Cc/McC","188","MS-DRG","","","","","","","","inpatient","","","11817.52","8863.14","MEDICARE [2001]","HB NWH MEDICARE","6832.19","","Case rate ($6,832.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,383.22, add-ons for qualifying new technology services are included. If operating cost exceeds $51,525.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,416.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,357.34. The transfer operating threshold is the transfer adjustment factor * $6,383.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.85. The transfer capital threshold is the transfer adjustment factor * $474.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1139.23","1139.23","1139.23","1 through 10","6089.49","7260.5038","other","Inpatient DRG"
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","AETNA [1001]","HB CH AETNA HMO / PPO","1081.09","58.3","","2190.90","412.50","9264.59","16","824.26","1444.73","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1075.53","58","","1903.20","1903.20","3826.66","1 through 10","824.26","1444.73","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1158.98","62.5","","2186.25","2186.25","2186.25","32","824.26","1444.73","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1353.68","73","","5556.60","5556.60","5556.60","1 through 10","824.26","1444.73","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","WELLPOINT [1015]","HB CH WELLPOINT","1444.73","77.91","","1955.15","885.83","3150.40","26","824.26","1444.73","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1854.36","1390.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","1099.64","59.3","","831.03","253.22","2394.88","18","927.18","1454.75","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1854.36","1390.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1454.75","78.45","","2481.69","1563.74","8149.28","1 through 10","927.18","1454.75","percent of total billed charges",""
"Plmt Bile Duct Stent Prq Existing Access","PX-36000381","CDM","47538","CPT","0361","RC","","","","both","","","1689.00","1266.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7135.79","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","5533.27","5533.27","5533.27","1 through 10","750.76","7135.79","other","OPPS APC"
"Plmt Bile Duct Stent Prq Existing Access","PX-36000381","CDM","47538","CPT","0361","RC","","","","both","","","1689.00","1266.75","MEDICARE [2001]","HB NWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6297.49","6928.65","1 through 10","750.76","7135.79","other","OPPS APC"
"Plmt Bile Duct Stent Prq Existing Access","PX-36000381","CDM","47538","CPT","0361","RC","","","","both","","","1689.00","1266.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6789.39","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20373.24","20373.24","20373.24","1 through 10","750.76","7135.79","other","OPPS APC"
"Plmt Nephrostomy Cath Prq New Access Rs&I|BILATERAL PROCEDURE","PX-76002184","CDM","50432","CPT","0761","RC","","","50","outpatient","","","1097.00","822.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2984.25","","Case rate ($2,984.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4315.23","4315.23","4315.23","1 through 10","2984.25","5801.21","other","ASC "
"Plmt Urtrl Stent Prq Pre-Existing Nfros Tract","PX-76002189","CDM","50693","CPT","0761","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","4013.54","","APC Price ($4,095.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4021.45","4021.45","4021.45","1 through 10","556.5","8517.58","other","OPPS APC"
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","2190.90","412.50","9264.59","16","60.01","105.18","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","1903.20","1903.20","3826.66","1 through 10","60.01","105.18","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","2186.25","2186.25","2186.25","32","60.01","105.18","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","5556.60","5556.60","5556.60","1 through 10","60.01","105.18","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","1955.15","885.83","3150.40","26","60.01","105.18","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","831.03","253.22","2394.88","18","67.5","105.91","percent of total billed charges",""
"PLUG BONE 5.5MM POLARIS TRIVIUM SCREW MULTIAXIAL TITANIUM FIXED HELICAL FLANGE DEROTATION DOUBLE RING","SUP-ITM-10048327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","2481.69","1563.74","8149.28","1 through 10","67.5","105.91","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1530.90","1160.93","1884.08","89","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","5253.92","5253.92","5253.92","1 through 10","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.96","58","","12181.47","12181.47","12181.47","1 through 10","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","101.25","62.5","","1350.68","1350.68","1350.68","1 through 10","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","1910.74","891.94","1910.74","1 through 10","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","1829.79","1561.50","2617.12","88","72.01","126.21","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1359.46","1201.30","1689.00","61","81","127.09","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","96.07","59.3","","1718.92","1718.92","1718.92","1 through 10","81","127.09","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","1910.74","1019.06","2344.84","74","81","127.09","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","1530.90","1160.93","1884.08","89","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","5253.92","5253.92","5253.92","1 through 10","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1653.00","58","","12181.47","12181.47","12181.47","1 through 10","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1781.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","1910.74","891.94","1910.74","1 through 10","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","1829.79","1561.50","2617.12","88","1266.83","2220.44","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","1359.46","1201.30","1689.00","61","1425","2235.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1690.05","59.3","","1718.92","1718.92","1718.92","1 through 10","1425","2235.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","1910.74","1019.06","2344.84","74","1425","2235.83","percent of total billed charges",""
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","23038.81","17279.11","MEDICARE [2001]","HB NWH MEDICARE","10472.16","","Case rate ($10,472.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,783.99, add-ons for qualifying new technology services are included. If operating cost exceeds $54,926.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,669.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,744.32. The transfer operating threshold is the transfer adjustment factor * $9,784.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $727.83. The transfer capital threshold is the transfer adjustment factor * $727.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10570.17","1844.80","10589.17","1 through 10","9333.77","11284.31","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","35947.40","26960.55","MEDICARE [2001]","HB NWH MEDICARE","16805.17","","Case rate ($16,805.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,700.85, add-ons for qualifying new technology services are included. If operating cost exceeds $60,843.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,109.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,637.18. The transfer operating threshold is the transfer adjustment factor * $15,700.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,167.99. The transfer capital threshold is the transfer adjustment factor * $1,167.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16878.61","16878.61","16878.61","1 through 10","14978.35","17457.0517","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","35947.40","26960.55","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","14978.35","","Case rate ($15,284.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,700.85, add-ons for qualifying new technology services are included. If operating cost exceeds $60,843.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,109.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,116.04. The transfer operating threshold is the transfer adjustment factor * $15,700.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,167.99. The transfer capital threshold is the transfer adjustment factor * $1,167.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15053.29","15053.29","15053.29","1 through 10","14978.35","17457.0517","other","Inpatient DRG"
"Pneumothorax Without Cc/McC","201","MS-DRG","","","","","","","","inpatient","","","15121.64","11341.23","MEDICARE [2001]","HB NWH MEDICARE","6195.57","","Case rate ($6,195.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,364.53, add-ons for qualifying new technology services are included. If operating cost exceeds $51,506.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,415.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,722.11. The transfer operating threshold is the transfer adjustment factor * $6,364.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.46. The transfer capital threshold is the transfer adjustment factor * $473.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6473.98","6473.98","6473.98","1 through 10","6071.66","6695.8419","other","Inpatient Replacement Plans DRG"
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","AETNA [1001]","HB CH AETNA HMO / PPO","37.50","58.3","","464.71","67.87","1012.10","221","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","37.50","58.3","","293.04","293.04","293.04","11","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.09","53","","983.89","983.89","983.89","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","37.31","58","","677.18","677.18","677.18","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","40.20","62.5","","46.58","46.58","46.58","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","46.95","73","","747.15","747.15","747.15","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.59","44.45","","1141.67","481.21","1141.67","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.59","44.45","","76.54","76.54","76.54","1 through 10","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","WELLPOINT [1015]","HB CH WELLPOINT","50.11","77.91","","273.64","94.28","1367.51","138","28.59","50.11","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.14","59.3","","720.78","230.14","2010.94","427","32.16","50.46","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","38.14","59.3","","344.45","344.45","344.45","1 through 10","32.16","50.46","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","50.46","78.45","","1120.13","1120.13","1120.13","1 through 10","32.16","50.46","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.46","78.45","","456.17","105.33","1284.66","242","32.16","50.46","percent of total billed charges",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","30803.81","23102.86","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1374.20","","Case rate ($1,374.20) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11163.45","11163.45","11163.45","1 through 10","1374.2","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","30803.81","23102.86","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","13362.96","13362.96","13362.96","1 through 10","1374.2","16099.63","case rate",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","30803.81","23102.86","MEDICARE [2001]","HB NWH MEDICARE","1374.20","","Case rate ($1,374.20) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15649.57","8251.18","15677.72","13","1374.2","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","30803.81","23102.86","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1374.20","","Case rate ($1,374.20) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","13983.49","13983.49","13983.49","1 through 10","1374.2","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","16043.89","12032.92","MEDICARE [2001]","HB NWH MEDICARE","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8442.75","8442.75","8457.93","1 through 10","1293.36","8798.13","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","16043.89","12032.92","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","6044.53","6044.53","6044.53","1 through 10","1293.36","8798.13","other","Inpatient Psych"
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","59426.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31460.10","","Standard inlier is a Case rate ($31,460.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $43,923, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,465.88) for the length of stay and the standard reimbursement.","30033.37","30033.37","30033.37","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","59426.85","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8148.0949","","Fee schedule rate ($50,316.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8148.0949","50316.68","50316.68","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","59426.85","","MASSHEALTH [3001]","HB NWH MEDICAID","15188.90","","Case rate ($16,363.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,793.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15332.45","15332.45","15332.45","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","59426.85","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","15188.90","","Case rate ($16,363.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $58,793.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16405.72","16405.72","16405.72","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17685.12","","Standard inlier is a Case rate ($17,685.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,790, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,510.47) for the length of stay and the standard reimbursement.","17685.12","17685.12","17685.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18997.35","","Standard inlier is a Case rate ($18,997.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,790, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,696.59) for the length of stay and the standard reimbursement.","18997.34","18997.34","18997.34","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7760.1282","","Fee schedule rate ($18,582.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7760.1282","24069.88","24069.88","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8148.0949","","Fee schedule rate ($19,511.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8148.0949","19511.52","19511.52","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","MASSHEALTH [3001]","HB NWH MEDICAID","6965.01","","Case rate ($7,503.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,933.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7522.99","7522.99","7522.99","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","6965.01","","Case rate ($7,503.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,933.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","18277.30","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6965.01","","Case rate ($7,503.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,933.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1757.71","1757.71","1757.71","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MINOR","812","DRG","","","","","","","","inpatient","","","8054.73","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7760.1282","","Fee schedule rate ($7,760.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7760.1282","7760.12","7760.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MINOR","812","DRG","","","","","","","","inpatient","","","8054.73","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8148.0949","","Fee schedule rate ($8,148.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8148.0949","8148.08","8148.08","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MINOR","812","DRG","","","","","","","","inpatient","","","8054.73","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4202.85","","Fee schedule rate ($4,202.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4202.85","4202.85","4202.85","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MINOR","812","DRG","","","","","","","","inpatient","","","8054.73","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8958.18","","Fee schedule rate ($8,958.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8958.18","8958.18","8958.18","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MODERATE","812","DRG","","","","","","","","inpatient","","","16535.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12071.19","","Standard inlier is a Case rate ($12,071.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,032, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,713.55) for the length of stay and the standard reimbursement.","12071.18","12071.18","12071.18","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MODERATE","812","DRG","","","","","","","","inpatient","","","16535.05","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7760.1282","","Fee schedule rate ($18,582.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7760.1282","9944.92","9944.92","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MODERATE","812","DRG","","","","","","","","inpatient","","","16535.05","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8148.0949","","Fee schedule rate ($19,511.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8148.0949","10442.12","10442.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MODERATE","812","DRG","","","","","","","","inpatient","","","16535.05","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5097.24","","Case rate ($5,491.47). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,921.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,283.05 and the sum of the standard inlier and any outlier amount.","3859.06","3859.06","3859.06","1 through 10","3572.45","79068.74","case rate",""
"Poliovirus Vaccine Inactivated Subq/Im","PX-63600318","CDM","90713","CPT","0636","RC","","","","outpatient","","","144.54","108.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","75.45","52.2","","74.44","74.44","74.44","1 through 10","72.27","113.39","percent of total billed charges",""
"Porphobilinogen Qn Urine","PX-30000622","CDM","84110","CPT","0301","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.06","58.3","","43.66","43.66","43.66","1 through 10","8.27","75.05","percent of total billed charges",""
"Porphobilinogen Qn Urine","PX-30000622","CDM","84110","CPT","0301","RC","","","","outpatient","","","79.00","59.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.85","59.3","","45.12","45.12","45.12","1 through 10","8.7","61.98","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","243.82","1 through 10","23.61","209.95","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.23","44.45","","165.29","165.29","165.29","1 through 10","23.61","209.95","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","92.83","92.83","92.83","1 through 10","18.62","173.37","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","18.62","173.37","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","477.00","357.75","AETNA [1001]","HB CH AETNA HMO / PPO","278.09","58.3","","270.46","270.46","331.70","1 through 10","252.81","371.63","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","477.00","357.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","348.21","73","","329.93","269.03","329.93","1 through 10","252.81","371.63","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","477.00","357.75","WELLPOINT [1015]","HB CH WELLPOINT","371.63","77.91","","375.69","375.69","375.69","1 through 10","252.81","371.63","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","477.00","357.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","282.86","59.3","","279.52","279.52","279.52","1 through 10","212.03","374.21","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","477.00","357.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","374.21","78.45","","366.72","217.32","449.75","1 through 10","212.03","374.21","percent of total billed charges",""
"PORT IMPLANTABLE 75CMX10FR DUAL PORT DUAL LUMEN INFUSION STD PROFILE SINGLE CHAMBER CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP INT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10005057","CDM","C1788","HCPCS","0278","RC","","","","both","","","984.00","738.00","AETNA [1001]","HB CH AETNA HMO / PPO","573.67","58.3","","270.46","270.46","331.70","1 through 10","521.52","766.63","percent of total billed charges",""
"PORT IMPLANTABLE 75CMX10FR DUAL PORT DUAL LUMEN INFUSION STD PROFILE SINGLE CHAMBER CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP INT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10005057","CDM","C1788","HCPCS","0278","RC","","","","both","","","984.00","738.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","718.32","73","","329.93","269.03","329.93","1 through 10","521.52","766.63","percent of total billed charges",""
"PORT IMPLANTABLE 75CMX10FR DUAL PORT DUAL LUMEN INFUSION STD PROFILE SINGLE CHAMBER CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP INT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10005057","CDM","C1788","HCPCS","0278","RC","","","","both","","","984.00","738.00","WELLPOINT [1015]","HB CH WELLPOINT","766.63","77.91","","375.69","375.69","375.69","1 through 10","521.52","766.63","percent of total billed charges",""
"PORT IMPLANTABLE 75CMX10FR DUAL PORT DUAL LUMEN INFUSION STD PROFILE SINGLE CHAMBER CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP INT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10005057","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","984.00","738.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","583.51","59.3","","279.52","279.52","279.52","1 through 10","437.39","771.95","percent of total billed charges",""
"PORT IMPLANTABLE 75CMX10FR DUAL PORT DUAL LUMEN INFUSION STD PROFILE SINGLE CHAMBER CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP INT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10005057","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","984.00","738.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","771.95","78.45","","366.72","217.32","449.75","1 through 10","437.39","771.95","percent of total billed charges",""
"PORT IMPLANTABLE 8FR 45CM INFUSION STD PROFILE SINGLE CHAMBER PLASTIC DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP IN","SUP-ITM-10091748","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","AETNA [1001]","HB CH AETNA HMO / PPO","608.65","58.3","","270.46","270.46","331.70","1 through 10","553.32","813.38","percent of total billed charges",""
"PORT IMPLANTABLE 8FR 45CM INFUSION STD PROFILE SINGLE CHAMBER PLASTIC DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP IN","SUP-ITM-10091748","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","762.12","73","","329.93","269.03","329.93","1 through 10","553.32","813.38","percent of total billed charges",""
"PORT IMPLANTABLE 8FR 45CM INFUSION STD PROFILE SINGLE CHAMBER PLASTIC DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP IN","SUP-ITM-10091748","CDM","C1788","HCPCS","0278","RC","","","","both","","","1044.00","783.00","WELLPOINT [1015]","HB CH WELLPOINT","813.38","77.91","","375.69","375.69","375.69","1 through 10","553.32","813.38","percent of total billed charges",""
"PORT IMPLANTABLE 8FR 45CM INFUSION STD PROFILE SINGLE CHAMBER PLASTIC DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP IN","SUP-ITM-10091748","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1044.00","783.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","619.09","59.3","","279.52","279.52","279.52","1 through 10","464.06","819.02","percent of total billed charges",""
"PORT IMPLANTABLE 8FR 45CM INFUSION STD PROFILE SINGLE CHAMBER PLASTIC DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED OPEN-ENDED TIP IN","SUP-ITM-10091748","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1044.00","783.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","819.02","78.45","","366.72","217.32","449.75","1 through 10","464.06","819.02","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1383.51","1037.63","AETNA [1001]","HB CH AETNA HMO / PPO","806.59","58.3","","270.46","270.46","331.70","1 through 10","733.26","1077.89","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1383.51","1037.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1009.96","73","","329.93","269.03","329.93","1 through 10","733.26","1077.89","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1383.51","1037.63","WELLPOINT [1015]","HB CH WELLPOINT","1077.89","77.91","","375.69","375.69","375.69","1 through 10","733.26","1077.89","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1383.51","1037.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","820.42","59.3","","279.52","279.52","279.52","1 through 10","614.97","1085.36","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1383.51","1037.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1085.36","78.45","","366.72","217.32","449.75","1 through 10","614.97","1085.36","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","555.00","416.25","AETNA [1001]","HB CH AETNA HMO / PPO","323.57","58.3","","270.46","270.46","331.70","1 through 10","294.15","432.4","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","555.00","416.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.15","73","","329.93","269.03","329.93","1 through 10","294.15","432.4","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","555.00","416.25","WELLPOINT [1015]","HB CH WELLPOINT","432.40","77.91","","375.69","375.69","375.69","1 through 10","294.15","432.4","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.12","59.3","","279.52","279.52","279.52","1 through 10","246.7","435.4","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","366.72","217.32","449.75","1 through 10","246.7","435.4","percent of total billed charges",""
"Positional Nystagmus","PX-47000069","CDM","92532","CPT","0920","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","306.82","58","","499.00","499.00","499.00","1 through 10","280.37","412.14","percent of total billed charges",""
"Positional Nystagmus","PX-47000069","CDM","92532","CPT","0920","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","330.63","62.5","","514.00","514.00","514.00","1 through 10","280.37","412.14","percent of total billed charges",""
"Positional Nystagmus","PX-47000069","CDM","92532","CPT","0920","RC","","","","outpatient","","","529.00","396.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","415.00","78.45","","395.16","395.16","395.16","1 through 10","226.94","415","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","AETNA [1001]","HB CH AETNA HMO / PPO","144.96","58.3","","464.71","67.87","1012.10","221","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.96","58.3","","293.04","293.04","293.04","11","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.78","53","","983.89","983.89","983.89","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","144.21","58","","677.18","677.18","677.18","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","155.40","62.5","","46.58","46.58","46.58","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","181.51","73","","747.15","747.15","747.15","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.52","44.45","","1141.67","481.21","1141.67","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.52","44.45","","76.54","76.54","76.54","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","WELLPOINT [1015]","HB CH WELLPOINT","193.72","77.91","","273.64","94.28","1367.51","138","110.52","193.72","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","147.44","59.3","","720.78","230.14","2010.94","427","124.32","195.06","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","147.44","59.3","","344.45","344.45","344.45","1 through 10","124.32","195.06","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","195.06","78.45","","1120.13","1120.13","1120.13","1 through 10","124.32","195.06","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","195.06","78.45","","456.17","105.33","1284.66","242","124.32","195.06","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","AETNA [1001]","HB CH AETNA HMO / PPO","159.51","58.3","","464.71","67.87","1012.10","221","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","159.51","58.3","","293.04","293.04","293.04","11","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","145.01","53","","983.89","983.89","983.89","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","158.69","58","","677.18","677.18","677.18","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","171.00","62.5","","46.58","46.58","46.58","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","199.73","73","","747.15","747.15","747.15","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","44.45","","1141.67","481.21","1141.67","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","44.45","","76.54","76.54","76.54","1 through 10","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.60","205.20","WELLPOINT [1015]","HB CH WELLPOINT","213.16","77.91","","273.64","94.28","1367.51","138","121.62","213.16","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.60","205.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","162.24","59.3","","720.78","230.14","2010.94","427","136.8","214.64","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.60","205.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","162.24","59.3","","344.45","344.45","344.45","1 through 10","136.8","214.64","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.60","205.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","214.64","78.45","","1120.13","1120.13","1120.13","1 through 10","136.8","214.64","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.60","205.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","214.64","78.45","","456.17","105.33","1284.66","242","136.8","214.64","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","AETNA [1001]","HB CH AETNA HMO / PPO","144.96","58.3","","464.71","67.87","1012.10","221","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.96","58.3","","293.04","293.04","293.04","11","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.78","53","","983.89","983.89","983.89","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","144.21","58","","677.18","677.18","677.18","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","155.40","62.5","","46.58","46.58","46.58","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","181.51","73","","747.15","747.15","747.15","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.52","44.45","","1141.67","481.21","1141.67","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.52","44.45","","76.54","76.54","76.54","1 through 10","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.64","186.48","WELLPOINT [1015]","HB CH WELLPOINT","193.72","77.91","","273.64","94.28","1367.51","138","110.52","193.72","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","147.44","59.3","","720.78","230.14","2010.94","427","124.32","195.06","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","147.44","59.3","","344.45","344.45","344.45","1 through 10","124.32","195.06","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","195.06","78.45","","1120.13","1120.13","1120.13","1 through 10","124.32","195.06","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.64","186.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","195.06","78.45","","456.17","105.33","1284.66","242","124.32","195.06","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","AETNA [1001]","HB CH AETNA HMO / PPO","2407.79","58.3","","464.71","67.87","1012.10","221","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2407.79","58.3","","293.04","293.04","293.04","11","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2188.90","53","","983.89","983.89","983.89","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2395.40","58","","677.18","677.18","677.18","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2581.25","62.5","","46.58","46.58","46.58","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3014.90","73","","747.15","747.15","747.15","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.79","44.45","","1141.67","481.21","1141.67","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.79","44.45","","76.54","76.54","76.54","1 through 10","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","WELLPOINT [1015]","HB CH WELLPOINT","3217.68","77.91","","273.64","94.28","1367.51","138","1835.79","3217.68","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2449.09","59.3","","720.78","230.14","2010.94","427","2065","3239.99","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2449.09","59.3","","344.45","344.45","344.45","1 through 10","2065","3239.99","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3239.99","78.45","","1120.13","1120.13","1120.13","1 through 10","2065","3239.99","percent of total billed charges",""
"POST BONE 6.5X30MM FREEDOM X","SUP-ITM-10297924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3239.99","78.45","","456.17","105.33","1284.66","242","2065","3239.99","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","AETNA [1001]","HB CH AETNA HMO / PPO","2325.00","58.3","","464.71","67.87","1012.10","221","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2325.00","58.3","","293.04","293.04","293.04","11","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.64","53","","983.89","983.89","983.89","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2313.04","58","","677.18","677.18","677.18","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2492.50","62.5","","46.58","46.58","46.58","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2911.24","73","","747.15","747.15","747.15","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.67","44.45","","1141.67","481.21","1141.67","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.67","44.45","","76.54","76.54","76.54","1 through 10","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","both","","","3988.00","2991.00","WELLPOINT [1015]","HB CH WELLPOINT","3107.05","77.91","","273.64","94.28","1367.51","138","1772.67","3107.05","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3988.00","2991.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2364.88","59.3","","720.78","230.14","2010.94","427","1994","3128.59","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3988.00","2991.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2364.88","59.3","","344.45","344.45","344.45","1 through 10","1994","3128.59","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3988.00","2991.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3128.59","78.45","","1120.13","1120.13","1120.13","1 through 10","1994","3128.59","percent of total billed charges",""
"POST FOOT SM 25MMXFUSION","SUP-ITM-10159359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3988.00","2991.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.59","78.45","","456.17","105.33","1284.66","242","1994","3128.59","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB CH AETNA HMO / PPO","454.74","58.3","","1530.90","1160.93","1884.08","89","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.40","53","","5253.92","5253.92","5253.92","1 through 10","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","452.40","58","","12181.47","12181.47","12181.47","1 through 10","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","487.50","62.5","","1350.68","1350.68","1350.68","1 through 10","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.71","44.45","","1910.74","891.94","1910.74","1 through 10","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","1829.79","1561.50","2617.12","88","346.71","607.7","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.54","59.3","","1359.46","1201.30","1689.00","61","390","611.91","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","462.54","59.3","","1718.92","1718.92","1718.92","1 through 10","390","611.91","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","1910.74","1019.06","2344.84","74","390","611.91","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB CH AETNA HMO / PPO","570.17","58.3","","1530.90","1160.93","1884.08","89","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.34","53","","5253.92","5253.92","5253.92","1 through 10","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","567.24","58","","12181.47","12181.47","12181.47","1 through 10","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","611.25","62.5","","1350.68","1350.68","1350.68","1 through 10","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.72","44.45","","1910.74","891.94","1910.74","1 through 10","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB CH WELLPOINT","761.96","77.91","","1829.79","1561.50","2617.12","88","434.72","761.96","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","1359.46","1201.30","1689.00","61","489","767.24","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","579.95","59.3","","1718.92","1718.92","1718.92","1 through 10","489","767.24","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","1910.74","1019.06","2344.84","74","489","767.24","percent of total billed charges",""
"Post-Extraction Dental Bleeding Control, Any Method","PX-76002959","CDM","41899","CPT","0761","RC","","","","outpatient","","","391.00","293.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.86","59.3","","2985.00","2985.00","2985.00","1 through 10","191.86","567.68","percent of total billed charges",""
"Post-Extraction Dental Bleeding Control, Any Method","PX-76002959","CDM","41899","CPT","0761","RC","","","","outpatient","","","391.00","293.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","225.61","57.7","","6371.30","6371.30","6371.30","1 through 10","191.86","567.68","percent of total billed charges",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","98200.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29617.85","","Standard inlier is a Case rate ($29,617.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,204.13) for the length of stay and the standard reimbursement.","108511.88","108511.88","108511.88","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","98200.07","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","149268.22","","Fee schedule rate ($149,268.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","149268.22","149268.22","149268.22","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","98200.07","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","61232.06","","Fee schedule rate ($61,232.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","155883.42","155883.42","155883.42","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","49541.95","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23342.919","","Fee schedule rate ($61,549.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23342.919","61549.48","61549.48","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","26707.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24894.98","","Standard inlier is a Case rate ($24,894.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,188, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,533.94) for the length of stay and the standard reimbursement.","23763.71","23763.71","23763.71","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","26707.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26742.18","","Standard inlier is a Case rate ($26,742.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $37,188, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,795.94) for the length of stay and the standard reimbursement.","2953.07","2953.07","2953.07","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","26707.79","","MASSHEALTH [3001]","HB NWH MEDICAID","14404.09","","Case rate ($15,518.14). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,948.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11750.12","11750.12","11750.12","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","34094.71","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23342.919","","Fee schedule rate ($33,987.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23342.919","32677.82","32677.82","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","34094.71","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","35686.64","","Fee schedule rate ($35,686.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35686.64","35686.64","35686.64","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","34094.71","","MASSHEALTH [3001]","HB NWH MEDICAID","14404.09","","Case rate ($15,518.14). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $57,948.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15558.04","15558.04","15558.04","1 through 10","12956.72","223902.34","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","24288.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","49402.63","","Standard inlier is a Case rate ($49,402.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $62,330, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,012.90) for the length of stay and the standard reimbursement.","49402.62","49402.62","49402.62","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","24288.58","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","60736.95","","Fee schedule rate ($60,736.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60736.95","60736.95","60736.95","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","28254.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29617.85","","Standard inlier is a Case rate ($29,617.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,204.13) for the length of stay and the standard reimbursement.","29617.84","28271.58","29617.84","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","28254.41","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","31276.68","","Fee schedule rate ($31,276.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31276.68","31276.68","31276.68","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","28254.41","","MASSHEALTH [3001]","HB NWH MEDICAID","12956.72","","Case rate ($13,958.81). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $56,388.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13994.72","13994.72","13994.72","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","28254.41","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","12415.54","","Fee schedule rate ($12,415.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12415.44","12415.44","12415.44","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","9416.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13265.07","","Standard inlier is a Case rate ($13,265.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,883.03) for the length of stay and the standard reimbursement.","13265.06","13265.06","13265.06","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","9416.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14249.33","","Standard inlier is a Case rate ($14,249.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,022.63) for the length of stay and the standard reimbursement.","13601.63","13601.63","13601.63","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","9416.10","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5974.57","","Case rate ($6,436.66). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,866.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6453.21","6453.21","6453.21","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17484.10","","Fee schedule rate ($17,484.10). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,022.64) multiplied by length of stay and the outlier percent (100%).","13987.27","13987.27","13987.27","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18781.41","","Fee schedule rate ($18,781.41). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,173.12) multiplied by length of stay and the outlier percent (100%).","17927.70","17927.70","17927.70","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12839.094","","Fee schedule rate ($17,867.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12839.094","17867.26","17867.26","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13480.983","","Fee schedule rate ($18,760.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13480.983","19653.79","19653.79","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","19653.79","","Fee schedule rate ($19,653.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19653.80","19653.80","19653.80","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18863.98","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19324.64","","Fee schedule rate ($19,324.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19324.64","19324.64","19324.64","1 through 10","5858.93","91105.42","case rate",""
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","28254.41","21190.81","MEDICARE [2001]","HB NWH MEDICARE","15800.40","","Case rate ($15,800.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,231.30, add-ons for qualifying new technology services are included. If operating cost exceeds $61,373.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,149.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,592.95. The transfer operating threshold is the transfer adjustment factor * $16,231.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,207.45. The transfer capital threshold is the transfer adjustment factor * $1,207.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17548.87","17235.85","17580.42","1 through 10","15484.39","18215.538","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","28254.41","21190.81","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15484.39","","Case rate ($15,800.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,231.30, add-ons for qualifying new technology services are included. If operating cost exceeds $61,373.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,149.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,592.95. The transfer operating threshold is the transfer adjustment factor * $16,231.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,207.45. The transfer capital threshold is the transfer adjustment factor * $1,207.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15681.22","15681.22","15681.22","1 through 10","15484.39","18215.538","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","18884.96","14163.72","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8645.74","","Case rate ($8,645.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,881.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,023.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,602.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,985.03. The transfer operating threshold is the transfer adjustment factor * $8,881.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $660.70. The transfer capital threshold is the transfer adjustment factor * $660.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7610.87","7610.87","7610.87","1 through 10","8472.83","10243.44","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","18884.96","14163.72","MEDICARE [2001]","HB NWH MEDICARE","8645.74","","Case rate ($8,645.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,881.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,023.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,602.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,985.03. The transfer operating threshold is the transfer adjustment factor * $8,881.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $660.70. The transfer capital threshold is the transfer adjustment factor * $660.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9543.22","9543.22","9560.38","1 through 10","8472.83","10243.44","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","18884.96","14163.72","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8472.83","","Case rate ($8,645.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,881.52, add-ons for qualifying new technology services are included. If operating cost exceeds $54,023.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,602.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,985.03. The transfer operating threshold is the transfer adjustment factor * $8,881.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $660.70. The transfer capital threshold is the transfer adjustment factor * $660.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8556.60","8556.60","8556.60","1 through 10","8472.83","10243.44","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","45843.65","34382.74","MEDICARE [2001]","HB NWH MEDICARE","18553.80","","Case rate ($18,553.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,059.79, add-ons for qualifying new technology services are included. If operating cost exceeds $64,202.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,359.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,135.94. The transfer operating threshold is the transfer adjustment factor * $19,059.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,417.86. The transfer capital threshold is the transfer adjustment factor * $1,417.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19289.42","19289.42","20795.80","1 through 10","18182.72","21982.5","other","Inpatient Replacement Plans DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","74758.59","56068.94","FALLON HEALTH [1008]","HB NWH MEDICARE","43331.84","","Case rate ($43,331.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,484.36, add-ons for qualifying new technology services are included. If operating cost exceeds $85,626.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,953.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $40,320.20. The transfer operating threshold is the transfer adjustment factor * $40,484.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,011.64. The transfer capital threshold is the transfer adjustment factor * $3,011.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38479.40","38479.40","38479.40","1 through 10","38621.41","46692.41","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","74758.59","56068.94","MEDICARE [2001]","HB NWH MEDICARE","43331.84","","Case rate ($43,331.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,484.36, add-ons for qualifying new technology services are included. If operating cost exceeds $85,626.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,953.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $40,320.20. The transfer operating threshold is the transfer adjustment factor * $40,484.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,011.64. The transfer capital threshold is the transfer adjustment factor * $3,011.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43136.89","23402.82","43136.89","1 through 10","38621.41","46692.41","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","74758.59","56068.94","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","38621.41","","Case rate ($39,409.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $40,484.36, add-ons for qualifying new technology services are included. If operating cost exceeds $85,626.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,953.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $36,397.96. The transfer operating threshold is the transfer adjustment factor * $40,484.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,011.64. The transfer capital threshold is the transfer adjustment factor * $3,011.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38462.63","38462.63","38462.63","1 through 10","38621.41","46692.41","other","Inpatient DRG"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","12193.64","9145.23","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5166.27","5166.27","5166.27","1 through 10","5558.82","6720.5","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,EXTREME","561","DRG","","","","","","","","inpatient","","","9616.62","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29704.49","","Fee schedule rate ($29,704.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29704.49","29704.49","29704.49","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","24444.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15184.59","","Standard inlier is a Case rate ($15,184.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,155.51) for the length of stay and the standard reimbursement.","37431.69","37431.69","37431.69","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","24444.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16311.28","","Standard inlier is a Case rate ($16,311.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,315.32) for the length of stay and the standard reimbursement.","16311.27","16311.27","16311.27","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","24444.27","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8226.0671","","Fee schedule rate ($16,224.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8226.0671","19314.43","19314.43","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","24444.27","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($16,224.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","19314.43","19314.43","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","24444.27","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6491.04","","Fee schedule rate ($6,491.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6491.04","6491.04","6491.04","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6393.51","","Standard inlier is a Case rate ($6,393.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,206, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($907.58) for the length of stay and the standard reimbursement.","11001.96","11001.96","11001.96","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6867.91","","Standard inlier is a Case rate ($6,867.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $18,206, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($974.87) for the length of stay and the standard reimbursement.","6867.90","5483.67","17859.17","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","6434.445","","Fee schedule rate ($7,978.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.471), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($28,489), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6434.445","7709.06","7709.06","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","7588.44","","Fee schedule rate ($7,978.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.471), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($28,489), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7588.44","7709.06","7709.06","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7834.3878","","Fee schedule rate ($7,834.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7834.3878","7834.38","7834.38","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($7,834.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","7834.38","7834.38","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","MASSHEALTH [3001]","HB NWH MEDICAID","3635.01","","Case rate ($3,916.15). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,346.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3926.22","3926.22","3926.22","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","8315.51","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2922.22","","Fee schedule rate ($2,922.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2922.22","2922.22","2922.22","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9707.94","","Standard inlier is a Case rate ($9,707.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,378.08) for the length of stay and the standard reimbursement.","9707.94","9267.21","12750.98","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10428.26","","Standard inlier is a Case rate ($10,428.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $21,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,480.25) for the length of stay and the standard reimbursement.","9954.25","8468.71","14829.28","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7834.3878","","Fee schedule rate ($9,116.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7834.3878","9116.34","9116.34","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($9,116.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","9116.34","9116.34","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10027.88","","Fee schedule rate ($10,027.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10027.88","10027.88","10027.88","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","MASSHEALTH [3001]","HB NWH MEDICAID","4783.09","","Case rate ($5,153.02). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,583.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5166.28","5166.28","5166.28","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15174.21","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8954.83","","Fee schedule rate ($8,954.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8694.09","8694.09","8694.09","1 through 10","2483.91","29704.49","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MAJOR","548","DRG","","","","","","","","inpatient","","","70866.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39611.60","","Standard inlier is a Case rate ($39,611.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,477, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,622.70) for the length of stay and the standard reimbursement.","39611.60","39611.60","39611.60","1 through 10","5193.2","39611.6","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MODERATE","548","DRG","","","","","","","","inpatient","","","45031.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22073.31","","Standard inlier is a Case rate ($22,073.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,292, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,133.39) for the length of stay and the standard reimbursement.","43379.66","43379.66","43379.66","1 through 10","5193.2","39611.6","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MODERATE","548","DRG","","","","","","","","inpatient","","","45031.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23711.13","","Standard inlier is a Case rate ($23,711.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $34,292, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,365.70) for the length of stay and the standard reimbursement.","22633.35","22633.35","23711.13","1 through 10","5193.2","39611.6","case rate",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","16","4.66","41.8","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","11","4.73","34.52","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","1 through 10","4.73","34.52","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","19.59","33.06","13","4.73","34.52","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.81","1 through 10","4.64","40.85","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.50","59.3","","90.09","24.61","90.09","1 through 10","4.43","33.73","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.73","78.45","","42.00","42.00","42.00","1 through 10","4.43","33.73","percent of total billed charges",""
"Potassium, Feces","PX-30001483","CDM","84999","CPT","0300","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","38.44","38.44","38.44","1 through 10","4.28","43.93","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","69.74","69.74","69.74","1 through 10","14.3","119.7","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","72.08","72.08","216.24","1 through 10","15.04","98.85","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","94.56","94.56","1 through 10","15.04","98.85","percent of total billed charges",""
"Precerebral Occlusion Without Infarction With McC","067","MS-DRG","","","","","","","","inpatient","","","35296.15","26472.11","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12724.71","","Case rate ($12,724.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,071.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,214.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,914.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,752.30. The transfer operating threshold is the transfer adjustment factor * $13,071.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.41. The transfer capital threshold is the transfer adjustment factor * $972.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12550.06","12550.06","12550.06","1 through 10","12470.22","14387.5061","other","Inpatient Replacement Plans DRG"
"Precerebral Occlusion Without Infarction Without McC","068","MS-DRG","","","","","","","","inpatient","","","27225.74","20419.30","MEDICARE [2001]","HB NWH MEDICARE","8234.45","","Case rate ($8,234.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,693.34, add-ons for qualifying new technology services are included. If operating cost exceeds $52,835.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,514.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,662.14. The transfer operating threshold is the transfer adjustment factor * $7,693.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.31. The transfer capital threshold is the transfer adjustment factor * $572.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8428.31","8428.31","8428.31","1 through 10","7339.32","8717.1535","other","Inpatient DRG"
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","92.42","92.42","92.42","1 through 10","20.26","159.6","percent of total billed charges",""
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","286.56","95.52","286.56","1 through 10","21.31","131.8","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","99.23","99.23","99.23","1 through 10","22.35","171","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","102.55","102.55","102.55","1 through 10","22.33","141.21","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","79.73","79.73","79.73","1 through 10","22.33","141.21","percent of total billed charges",""
"Prep Wound F/Nhf/G 1st 100cm Child","PX-76000165","CDM","15004","CPT","0761","RC","","","","both","","","1376.00","1032.00","WELLPOINT [1015]","HB CH WELLPOINT","1072.04","77.91","","4160.89","4160.89","4160.89","1 through 10","267.79","1072.04","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","29","60.9","404.7","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","TRICARE [160005]","HB NWH TRICARE","404.70","95","","74.88","71.14","74.88","1 through 10","60.9","404.7","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.36","44.45","","188.62","188.62","188.62","1 through 10","60.9","404.7","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","236.81","1141.80","37","176.68","603.55","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","28","176.68","603.55","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0510","RC","","","","both","","","147.00","110.25","AETNA [1001]","HB CH AETNA HMO / PPO","85.70","58.3","","81.08","81.08","81.08","1 through 10","85.7","85.7","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0510","RC","","","","both","","","245.00","183.75","AETNA [1001]","HB CH AETNA HMO / PPO","142.84","58.3","","134.95","134.95","134.95","1 through 10","142.84","142.84","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","outpatient","","","245.00","183.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","145.29","59.3","","139.47","139.47","139.47","1 through 10","79.3","192.2","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","192.20","78.45","","182.97","182.97","182.98","1 through 10","79.3","192.2","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0510","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","102.03","102.03","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","130.70","130.70","130.70","1 through 10","77.79","137.29","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0510","RC","","","","both","","","198.00","148.50","AETNA [1001]","HB CH AETNA HMO / PPO","115.43","58.3","","109.43","109.43","109.43","1 through 10","115.43","188.1","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","outpatient","","","198.00","148.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","117.41","59.3","","113.10","113.10","113.10","1 through 10","79.3","155.33","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","outpatient","","","198.00","148.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","117.41","59.3","","110.40","110.40","110.40","1 through 10","79.3","155.33","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","155.33","78.45","","148.38","87.93","148.38","1 through 10","79.3","155.33","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0510","RC","","","","both","","","198.00","148.50","AETNA [1001]","HB CH AETNA HMO / PPO","115.43","58.3","","109.43","109.43","109.43","43","115.43","115.43","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","198.00","148.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","117.41","59.3","","113.10","113.10","113.10","46","79.3","155.33","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","155.33","78.45","","148.38","87.93","148.38","33","79.3","155.33","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0510","RC","","","","both","","","224.00","168.00","AETNA [1001]","HB CH AETNA HMO / PPO","130.59","58.3","","123.61","123.61","123.61","67","130.59","130.59","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","224.00","168.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","163.52","73","","123.61","123.61","123.61","1 through 10","118.72","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","224.00","168.00","TRICARE [160005]","HB NWH TRICARE","212.80","95","","91.99","91.99","91.99","1 through 10","118.72","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","127.75","379.73","47","79.3","175.73","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","167.60","167.60","167.60","1 through 10","79.3","175.73","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","99.32","167.60","63","79.3","175.73","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0510","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","102.03","102.03","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","outpatient","","","175.00","131.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.78","59.3","","99.62","99.62","99.62","1 through 10","77.79","137.29","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","130.70","130.70","130.70","1 through 10","77.79","137.29","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0510","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","102.03","102.03","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","224.00","168.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","163.52","73","","1312.00","1312.00","1312.00","1 through 10","118.72","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","127.75","127.75","1 through 10","79.3","175.73","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0510","RC","","","","both","","","275.00","206.25","AETNA [1001]","HB CH AETNA HMO / PPO","160.33","58.3","","151.39","141.56","151.39","1 through 10","160.33","160.33","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","outpatient","","","275.00","206.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","163.08","59.3","","156.46","156.46","156.46","1 through 10","79.3","215.74","percent of total billed charges",""
"Prgenancy-Assoc Plasma Protein-A","PX-30000649","CDM","84163","CPT","0301","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","15.53","94.96","percent of total billed charges",""
"Prgrmg Dev Eval Scrms Phys/Qhp Remote","PX-48000481","CDM","0650T","CPT","0480","RC","","","","both","","","726.00","544.50","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","43.39","690.43","other","OPPS APC"
"Prgrmg Dev Eval Scrms Phys/Qhp Remote","PX-48000481","CDM","0650T","CPT","0480","RC","","","","both","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","43.90","43.90","1 through 10","43.39","690.43","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","1456.00","1092.00","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","1062.88","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","1456.00","1092.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.99","43.99","43.99","1 through 10","42.07","1062.88","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","1456.00","1092.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.60","43.60","43.60","1 through 10","42.07","1062.88","other","OPPS APC"
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","AETNA [1001]","HB CH AETNA HMO / PPO","1287.26","58.3","","2190.90","412.50","9264.59","16","981.46","1720.25","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1280.64","58","","1903.20","1903.20","3826.66","1 through 10","981.46","1720.25","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1380.00","62.5","","2186.25","2186.25","2186.25","32","981.46","1720.25","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1611.84","73","","5556.60","5556.60","5556.60","1 through 10","981.46","1720.25","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","WELLPOINT [1015]","HB CH WELLPOINT","1720.25","77.91","","1955.15","885.83","3150.40","26","981.46","1720.25","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2208.00","1656.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1309.34","59.3","","831.03","253.22","2394.88","18","1104","1732.18","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2208.00","1656.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1732.18","78.45","","2481.69","1563.74","8149.28","1 through 10","1104","1732.18","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0300","RC","","","","inpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.90","70.6","","81.55","81.55","81.55","1 through 10","103.04","129.9","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","184.00","138.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.11","59.3","","205.54","104.89","537.00","1 through 10","27.61","168.81","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","144.35","78.45","","137.62","131.94","137.62","1 through 10","27.61","168.81","percent of total billed charges",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","40573.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","43082.42","","Standard inlier is a Case rate ($43,082.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $52,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,115.37) for the length of stay and the standard reimbursement.","43082.42","43082.42","43082.42","1 through 10","14991.27","153726.49","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","65931.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","54396.33","","Standard inlier is a Case rate ($54,396.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $67,451, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,721.77) for the length of stay and the standard reimbursement.","54396.33","54396.33","54396.33","1 through 10","14991.27","153726.49","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","65931.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","58432.51","","Standard inlier is a Case rate ($58,432.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $67,451, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,294.25) for the length of stay and the standard reimbursement.","58432.51","58432.51","58432.51","1 through 10","14991.27","153726.49","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27120.94","","Standard inlier is a Case rate ($27,120.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,849.92) for the length of stay and the standard reimbursement.","25890.58","25888.52","27120.94","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29133.30","","Standard inlier is a Case rate ($29,133.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,135.35) for the length of stay and the standard reimbursement.","27812.03","27809.06","29133.30","12","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24237.9426","","Fee schedule rate ($24,237.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24237.9426","24237.94","25737.94","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","25449.7157","","Fee schedule rate ($25,449.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25449.7157","25449.72","25449.72","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","25449.72","","Fee schedule rate ($25,449.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25449.72","25449.72","25449.72","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","MASSHEALTH [3001]","HB NWH MEDICAID","8712.83","","Case rate ($9,386.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,816.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9410.83","9410.83","9410.83","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","12073.39","","Fee schedule rate ($12,073.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12073.39","12073.39","12073.39","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","27291.30","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25733.85","","Fee schedule rate ($25,733.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25733.85","25733.85","25733.85","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27120.94","","Standard inlier is a Case rate ($27,120.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,849.92) for the length of stay and the standard reimbursement.","23615.30","23615.30","23615.30","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29133.30","","Standard inlier is a Case rate ($29,133.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,135.35) for the length of stay and the standard reimbursement.","32285.96","32285.96","32285.96","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24237.9426","","Fee schedule rate ($27,075.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24237.9426","27075.44","27075.44","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","25449.7157","","Fee schedule rate ($28,429.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25449.7157","33843.61","33843.61","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","33843.61","","Fee schedule rate ($33,843.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33843.61","33843.61","33843.61","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","29782.71","","Fee schedule rate ($29,782.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29782.71","29782.71","29782.71","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","28429.07","","Fee schedule rate ($28,429.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28429.07","28429.07","28429.07","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25733.85","","Fee schedule rate ($25,733.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30761.54","30761.54","30761.54","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","8712.83","","Case rate ($9,386.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,816.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10304.17","10304.17","10304.17","1 through 10","8712.83","44674.06","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","24945.50","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8712.83","","Case rate ($9,386.69). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,816.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10304.17","10304.17","10304.17","1 through 10","8712.83","44674.06","case rate",""
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","972.00","729.00","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","709.56","other","OPPS APC"
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","972.00","729.00","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","44.28","1 through 10","42.07","709.56","other","OPPS APC"
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","972.00","729.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","43.39","43.39","1 through 10","42.07","709.56","other","OPPS APC"
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","972.00","729.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.40","43.40","43.40","1 through 10","42.07","709.56","other","OPPS APC"
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","outpatient","","","972.00","729.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","762.53","78.45","","726.52","726.52","726.52","1 through 10","61.36","762.53","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","101","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","87.85","1 through 10","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","43.39","130.17","19","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","43.39","44.28","1 through 10","42.07","692.77","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","949.00","711.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.83","44.45","","709.60","709.60","709.60","1 through 10","42.07","692.77","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","949.00","711.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","562.76","59.3","","540.88","540.88","540.88","1 through 10","61.36","744.49","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","744.49","78.45","","88.44","88.44","88.44","1 through 10","61.36","744.49","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1547.00","1160.25","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","1129.31","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1547.00","1160.25","MOLINA [1014]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.85","87.85","87.85","1 through 10","42.07","1129.31","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.40","43.40","43.40","1 through 10","42.07","1129.31","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1115.00","836.25","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","813.95","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1115.00","836.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","40.34","40.34","40.34","1 through 10","42.07","813.95","other","OPPS APC"
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","174.00","130.50","AETNA [1001]","HB CH AETNA HMO / PPO","101.44","58.3","","95.82","95.82","95.82","160","20.44","165.3","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","174.00","130.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127.02","73","","27.23","27.23","27.23","1 through 10","20.44","165.3","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.18","59.3","","99.03","99.03","99.03","100","21.52","136.5","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.34","44.45","","75.88","75.88","75.88","1 through 10","21.52","136.5","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.50","78.45","","129.93","129.93","129.93","104","21.52","136.5","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.34","44.45","","129.93","129.93","129.93","1 through 10","21.52","136.5","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","outpatient","","","156.00","117.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","1 through 10","18.37","122.38","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","124.17","124.17","124.17","92","18.99","213.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","124.17","124.17","124.17","1 through 10","18.99","213.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","TRICARE [160005]","HB NWH TRICARE","213.75","95","","23.35","22.18","23.35","1 through 10","18.99","213.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","99.78","99.78","99.78","1 through 10","18.99","213.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","168.37","168.37","168.37","1 through 10","18.99","213.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","128.33","128.33","128.33","87","19.98","176.51","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","168.37","99.78","168.37","81","19.98","176.51","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","293.00","219.75","AETNA [1001]","HB CH AETNA HMO / PPO","170.82","58.3","","161.60","161.60","161.60","1 through 10","40.93","278.35","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","293.00","219.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.75","59.3","","167.01","167.01","167.01","1 through 10","25.74","229.86","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","293.00","219.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.24","44.45","","219.11","219.11","219.11","1 through 10","25.74","229.86","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","293.00","219.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.86","78.45","","219.11","219.11","219.11","1 through 10","25.74","229.86","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","311","18.92","144.4","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.96","73","","83.92","17.37","86.73","1 through 10","18.92","144.4","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.56","44.45","","67.43","66.45","113.78","1 through 10","18.92","144.4","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","296","18.96","123.05","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","152.00","114.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","109.19","113.78","1 through 10","18.96","123.05","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","67.43","113.78","312","18.96","123.05","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","17","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","152.00","114.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","110.96","73","","108.04","108.04","108.04","1 through 10","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","11","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","67.43","113.78","11","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","129","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","110.96","73","","108.04","108.04","108.04","1 through 10","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.96","73","","50.32","38.11","50.32","1 through 10","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","TRICARE [160005]","HB NWH TRICARE","144.40","95","","22.16","21.05","22.16","1 through 10","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.56","44.45","","113.78","67.43","113.78","1 through 10","18.02","144.4","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","138","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","67.43","113.78","155","18.96","119.24","percent of total billed charges",""
"PROSTHESIS BOJRAB UNIVERSAL HA/OTOSIL","SUP-ITM-10266998","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1464.21","1098.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","868.28","59.3","","782.24","782.24","782.24","1 through 10","732.11","1148.67","percent of total billed charges",""
"PROSTHESIS EAR 1.75 TO 4.50MM MIDDLE PARTIAL TTP VARIO BELL TI VARIABLE LENGTH","SUP-ITM-10214747","CDM","L8613","HCPCS","0278","RC","","","","outpatient","","","1334.88","1001.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.58","59.3","","782.24","782.24","782.24","1 through 10","667.44","1047.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","AETNA [1001]","HB CH AETNA HMO / PPO","1518.13","58.3","","1530.90","1160.93","1884.08","89","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1380.12","53","","5253.92","5253.92","5253.92","1 through 10","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1510.32","58","","12181.47","12181.47","12181.47","1 through 10","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1627.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1157.48","44.45","","1910.74","891.94","1910.74","1 through 10","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","WELLPOINT [1015]","HB CH WELLPOINT","2028.78","77.91","","1829.79","1561.50","2617.12","88","1157.48","2028.78","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1544.17","59.3","","1359.46","1201.30","1689.00","61","1302","2042.84","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1544.17","59.3","","1718.92","1718.92","1718.92","1 through 10","1302","2042.84","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2042.84","78.45","","1910.74","1019.06","2344.84","74","1302","2042.84","percent of total billed charges",""
"PROSTHESIS OSSICULAR CROWN KRAUS K HELIX TI CUP 1.45MM COIL 2.75MM","SUP-ITM-10124303","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1491.69","1118.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","884.57","59.3","","782.24","782.24","782.24","1 through 10","745.85","1170.23","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","both","","","4078.00","3058.50","AETNA [1001]","HB CH AETNA HMO / PPO","2377.47","58.3","","416.75","416.75","416.75","1 through 10","1812.67","3177.17","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4078.00","3058.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2418.25","59.3","","7893.60","423.68","7893.60","1 through 10","2039","3199.19","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4078.00","3058.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3199.19","78.45","","555.84","329.40","555.84","1 through 10","2039","3199.19","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","both","","","5338.00","4003.50","AETNA [1001]","HB CH AETNA HMO / PPO","3112.05","58.3","","416.75","416.75","416.75","1 through 10","2372.74","4158.84","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5338.00","4003.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3165.43","59.3","","7893.60","423.68","7893.60","1 through 10","2669","4187.66","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5338.00","4003.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4187.66","78.45","","555.84","329.40","555.84","1 through 10","2669","4187.66","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","both","","","5476.00","4107.00","AETNA [1001]","HB CH AETNA HMO / PPO","3192.51","58.3","","416.75","416.75","416.75","1 through 10","2434.08","4266.35","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5476.00","4107.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3247.27","59.3","","7893.60","423.68","7893.60","1 through 10","2738","4295.92","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5476.00","4107.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4295.92","78.45","","555.84","329.40","555.84","1 through 10","2738","4295.92","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","both","","","4192.00","3144.00","AETNA [1001]","HB CH AETNA HMO / PPO","2443.94","58.3","","416.75","416.75","416.75","1 through 10","1863.34","3265.99","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4192.00","3144.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2485.86","59.3","","7893.60","423.68","7893.60","1 through 10","2096","3288.62","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4192.00","3144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3288.62","78.45","","555.84","329.40","555.84","1 through 10","2096","3288.62","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.81","78.81","78.81","1 through 10","13.56","135.85","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.45","81.45","81.45","1 through 10","13.15","112.18","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.86","63.33","106.86","1 through 10","13.15","112.18","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","1 through 10","11.77","129.2","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","AETNA [1001]","HB CH AETNA HMO / PPO","53.64","58.3","","50.46","50.46","50.46","47","10.53","87.4","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","67.16","73","","64.97","64.97","64.97","1 through 10","10.53","87.4","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","67.16","73","","64.97","64.97","64.97","1 through 10","10.53","87.4","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","TRICARE [160005]","HB NWH TRICARE","87.40","95","","12.94","12.94","12.94","1 through 10","10.53","87.4","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","92.00","69.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.56","59.3","","52.15","52.15","260.75","44","11.07","72.17","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","92.00","69.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.17","78.45","","68.42","40.55","68.42","35","11.07","72.17","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","157.00","117.75","AETNA [1001]","HB CH AETNA HMO / PPO","91.53","58.3","","86.75","86.75","86.75","1 through 10","17.47","149.15","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","157.00","117.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.10","59.3","","89.66","89.66","89.66","1 through 10","18.4","123.17","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","117.63","69.71","117.63","1 through 10","18.4","123.17","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.77","76.77","76.77","1 through 10","14.72","105.91","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","99.00","74.25","AETNA [1001]","HB CH AETNA HMO / PPO","57.72","58.3","","54.43","54.43","54.43","1 through 10","11.38","94.05","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","56.26","56.26","56.26","1 through 10","11.97","77.67","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","73.80","43.74","73.80","1 through 10","11.97","77.67","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","41.00","30.75","AETNA [1001]","HB CH AETNA HMO / PPO","23.90","58.3","","22.68","22.68","22.68","1 through 10","3.92","38.95","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.16","78.45","","30.75","18.22","30.75","1 through 10","3.77","32.16","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0300","RC","","","","inpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","23.52","56","","24.03","24.03","24.03","1 through 10","23.52","29.65","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","140","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","CHAMPVA [160001]","HB NWH TRICARE","39.90","95","","4.42","4.42","4.42","1 through 10","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","30.66","73","","29.93","29.93","29.93","1 through 10","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","30.66","73","","23.25","23.25","23.25","1 through 10","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","TRICARE [160005]","HB NWH TRICARE","39.90","95","","4.42","4.20","45.42","1 through 10","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.67","44.45","","18.68","18.68","18.68","1 through 10","3.6","39.9","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","72.09","132","3.77","32.95","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","18.68","31.52","98","3.77","32.95","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","AETNA [1001]","HB CH AETNA HMO / PPO","18.07","58.3","","17.01","17.01","17.01","33","3.6","29.45","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","22.63","73","","21.90","21.90","21.90","1 through 10","3.6","29.45","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","TRICARE [160005]","HB NWH TRICARE","29.45","95","","34.42","34.42","34.42","1 through 10","3.6","29.45","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","31.00","23.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","18.38","59.3","","17.58","17.58","87.90","34","3.77","24.32","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.32","78.45","","23.06","13.67","23.06","25","3.77","24.32","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0300","RC","","","","inpatient","","","35.00","26.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.60","56","","18.80","18.80","18.80","1 through 10","19.6","24.71","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0300","RC","","","","inpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.71","70.6","","26.14","15.49","26.14","1 through 10","19.6","24.71","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","AETNA [1001]","HB CH AETNA HMO / PPO","20.41","58.3","","19.28","19.28","19.28","143","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","25.55","73","","24.82","24.82","24.82","1 through 10","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","18.55","53","","18.02","18.02","18.02","1 through 10","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","25.55","73","","18.61","18.61","19.28","1 through 10","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","TRICARE [160005]","HB NWH TRICARE","33.25","95","","5.17","5.17","34.00","1 through 10","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.56","44.45","","25.02","15.49","26.14","1 through 10","4.2","33.25","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.76","59.3","","19.92","19.92","22.71","173","4.06","27.46","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","20.76","59.3","","19.92","19.92","19.92","1 through 10","4.06","27.46","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","27.46","78.45","","26.14","26.14","26.14","1 through 10","4.06","27.46","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.46","78.45","","26.14","15.49","26.14","142","4.06","27.46","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","101.65","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","44.72","44.72","44.72","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","101.65","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","44.72","44.72","44.72","1 through 10","9.6","83.94","percent of total billed charges",""
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","MEDICARE [2001]","HB NWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7464.40","7793.84","1 through 10","968.31","8026.84","other","OPPS APC"
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,788). Procedure 2, Per diem ($894). Procedures 3 - 9999, Per diem ($447).","1685.00","1685.00","1685.00","1 through 10","968.31","8026.84","per diem",""
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.87","7645.87","7645.87","1 through 10","968.31","8026.84","other","OPPS APC"
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","outpatient","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1433.28","78.45","","5828.27","5828.27","5828.27","1 through 10","781.72","5381.58","percent of total billed charges",""
"Prq Plmt Biliary Drg Cath W/Img Gid Rs&I Int-Ext","PX-36000377","CDM","47534","CPT","0361","RC","","","","both","","","1507.00","1130.25","MEDICARE [2001]","HB NWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","798.71","9590.18","other","OPPS APC"
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","456.00","342.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","149.96","433.66","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","125.87","125.87","125.87","82","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","144.55","63.4","","123.11","48.83","286.90","1 through 10","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","132.24","58","","181.86","181.86","181.86","1 through 10","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","213.96","207.76","213.96","17","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","138.85","60.9","","213.96","213.96","213.96","1 through 10","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","222.00","222.00","666.00","58","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","125.88","125.88","125.88","1 through 10","101.35","216.83","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","130.09","130.09","130.09","1 through 10","79.3","344","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","673","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","76.08","63.4","","44.14","27.50","70.05","73","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","69.60","58","","24.11","24.11","24.11","80","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.60","58","","28.36","27.54","28.36","249","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","73.08","60.9","","29.78","28.36","29.78","30","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.00","62.5","","31.26","30.35","31.26","626","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","66.35","66.34","114.00","1 through 10","53.34","157.62","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","45.75","304.13","26","69.24","344","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","75.00","75.00","75.00","1 through 10","69.24","344","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","357.00","267.75","AETNA [1001]","HB CH AETNA HMO / PPO","208.13","58.3","","196.75","196.75","196.75","1 through 10","141.78","339.51","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","223.13","62.5","","292.62","284.15","292.62","1 through 10","141.78","339.51","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","480.00","360.00","AETNA [1001]","HB CH AETNA HMO / PPO","279.84","58.3","","197.17","197.17","264.79","1 through 10","213.36","456.48","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","276.96","57.7","","438.93","438.93","440.44","1 through 10","122.71","376.56","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","290.40","60.5","","460.87","460.87","462.46","1 through 10","122.71","376.56","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","197.17","197.17","264.79","1 through 10","280.04","598.5","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","309.14","49.07","","28.28","28.28","28.88","1 through 10","122.71","494.24","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","315.63","50.1","","28.92","28.32","28.92","1 through 10","122.71","494.24","percent of total billed charges",""
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1212.53","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16518.79","14817.59","23089.88","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","42681.06","42681.06","42681.06","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","ELDER SERVICES [1037]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","34300.00","34300.00","34300.00","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","FALLON HEALTH [1008]","HB NWH MEDICAID","","","APC Rate ($695.29). Includes reimbursement for any outliers.","1162.29","1162.29","1815.93","1 through 10","1154.79","14338.15","fee schedule",""
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","HUMANA [1012]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","83207.74","83207.74","83207.74","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","MEDICARE [2001]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","13453.46","5518.21","41160.81","73","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","MOLINA [1014]","HB NWH MEDICARE","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","34016.21","34016.21","34016.21","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15290.00","13689.30","50457.00","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14158.32","918.90","19512.12","16","1154.79","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38271.22","28703.41","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1154.79","","Case rate ($1,154.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12038.87","12038.87","12038.87","1 through 10","1154.79","14338.15","other","Inpatient Psych"
"Pt Canalith Repositioning per Day","PX-42000007","CDM","95992","CPT","0421","RC","","","","both","","","204.00","153.00","AETNA [1001]","HB CH AETNA HMO / PPO","118.93","58.3","","112.27","112.27","112.27","1 through 10","36.25","364.8","percent of total billed charges",""
"Pt E-Stim Attended 15 Min","PX-42000017","CDM","97032","CPT","0421","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB NWH TRICARE","97.85","95","","15.74","15.74","15.74","1 through 10","15.37","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","167.51","72.52","167.79","1073","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.86","58.3","","95.26","95.26","95.26","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","51.05","51.05","51.05","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","190.51","115.34","556.99","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB NWH TRICARE","164.35","95","","32.64","32.11","65.28","76","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.45","23.78","32.11","634","31.47","364.8","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","192.19","16","86.5","232","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","77.33","51.22","120.67","1 through 10","86.5","232","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.00","62.78","82.78","30","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","14.18","14.18","14.18","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","TRICARE [160005]","HB NWH TRICARE","142.50","95","","91.51","61.01","91.51","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.79","23.31","26.65","13","31.47","364.8","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","75.57","206.39","24","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","136.51","73","","103.19","103.19","103.19","1 through 10","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB NWH TRICARE","177.65","95","","35.97","34.17","68.34","1 through 10","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.74","28.89","35.27","11","35.26","364.8","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","110.89","59.3","","106.61","106.61","106.61","1 through 10","93.5","251.62","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","66.96","66.96","87.89","315","29.66","364.8","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","116.07","73","","226.30","106.58","226.30","1 through 10","29.66","364.8","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","TRICARE [160005]","HB NWH TRICARE","151.05","95","","30.27","29.95","60.54","26","29.66","364.8","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.13","22.08","22.44","183","29.66","364.8","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","159.00","119.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","1 through 10","79.5","232","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","124.74","78.45","","111.33","73.24","111.33","1 through 10","79.5","232","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","175.39","99.79","175.39","340","35.02","364.8","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","132.13","73","","121.18","121.18","121.18","1 through 10","35.02","364.8","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","TRICARE [160005]","HB NWH TRICARE","171.95","95","","35.72","35.72","112.68","1 through 10","35.02","364.8","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","29.27","26.43","35.62","151","35.02","364.8","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.99","78.45","","77.33","58.00","77.33","1 through 10","90.5","240.73","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","14","51.33","364.8","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB NWH TRICARE","196.65","95","","52.37","52.37","52.37","1 through 10","51.33","364.8","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","51.33","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($52.38). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($34.76). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","52.24","51.84","52.24","1 through 10","51.33","364.8","fee schedule",""
"Pt Performance Test 15 Min","PX-42000044","CDM","97750","CPT","0421","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","36.78","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($37.53). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.49). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","36.78","31.44","36.87","1 through 10","36.78","364.8","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","172.62","71.69","172.62","72","38.35","364.8","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","TRICARE [160005]","HB NWH TRICARE","173.85","95","","82.92","39.39","148.66","13","38.35","364.8","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","32.31","29.62","38.35","70","38.35","364.8","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","104.31","1 through 10","91.5","254.62","percent of total billed charges",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB CH AETNA HMO / PPO","39.64","58.3","","28.28","28.28","28.51","1 through 10","15.19","364.8","percent of total billed charges",""
"Pt Wheelchair Manage 15 Min","PX-42000036","CDM","97542","CPT","0421","RC","","","","both","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","33.59","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($34.28). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.37). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","24.87","24.87","24.87","1 through 10","33.59","364.8","fee schedule",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","1 through 10","6.34","71.25","percent of total billed charges",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","42.78","1 through 10","6.67","58.84","percent of total billed charges",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","24368.50","18276.37","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11024.51","","Case rate ($10,703.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,995.32, add-ons for qualifying new technology services are included. If operating cost exceeds $56,137.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,759.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,885.47. The transfer operating threshold is the transfer adjustment factor * $10,995.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.94. The transfer capital threshold is the transfer adjustment factor * $817.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11117.84","11117.84","11117.84","1 through 10","10489.34","12236.6486","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","24368.50","18276.37","MEDICARE [2001]","HB NWH MEDICARE","11768.67","","Case rate ($11,768.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,995.32, add-ons for qualifying new technology services are included. If operating cost exceeds $56,137.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,759.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,950.73. The transfer operating threshold is the transfer adjustment factor * $10,995.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.94. The transfer capital threshold is the transfer adjustment factor * $817.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11809.96","11809.81","11831.19","25","10489.34","12236.6486","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","24368.50","18276.37","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","10489.34","","Case rate ($10,703.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,995.32, add-ons for qualifying new technology services are included. If operating cost exceeds $56,137.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,759.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,885.47. The transfer operating threshold is the transfer adjustment factor * $10,995.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.94. The transfer capital threshold is the transfer adjustment factor * $817.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11982.45","11982.45","11982.45","1 through 10","10489.34","12236.6486","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","31148.61","23361.46","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","11900.77","","Case rate ($11,900.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,225.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,367.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,851.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,991.32. The transfer operating threshold is the transfer adjustment factor * $12,225.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.44. The transfer capital threshold is the transfer adjustment factor * $909.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12151.15","12151.15","12151.15","1 through 10","11662.75","13934.5899","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","31148.61","23361.46","MEDICARE [2001]","HB NWH MEDICARE","11900.77","","Case rate ($11,900.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,225.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,367.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,851.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,991.32. The transfer operating threshold is the transfer adjustment factor * $12,225.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.44. The transfer capital threshold is the transfer adjustment factor * $909.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13448.69","10617.75","13472.86","17","11662.75","13934.5899","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","31148.61","23361.46","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11662.75","","Case rate ($11,900.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,225.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,367.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,851.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,991.32. The transfer operating threshold is the transfer adjustment factor * $12,225.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.44. The transfer capital threshold is the transfer adjustment factor * $909.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9491.62","9491.62","9497.95","1 through 10","11662.75","13934.5899","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","31148.61","23361.46","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","11662.75","","Case rate ($11,900.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,225.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,367.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,851.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,991.32. The transfer operating threshold is the transfer adjustment factor * $12,225.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.44. The transfer capital threshold is the transfer adjustment factor * $909.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","58.57","58.57","58.57","1 through 10","11662.75","13934.5899","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","31148.61","23361.46","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","11662.75","","Case rate ($11,900.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,225.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,367.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,851.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,991.32. The transfer operating threshold is the transfer adjustment factor * $12,225.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.44. The transfer capital threshold is the transfer adjustment factor * $909.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12050.57","12050.57","12050.57","1 through 10","11662.75","13934.5899","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","21424.74","16068.55","MEDICARE [2001]","HB NWH MEDICARE","7668.59","","Case rate ($7,668.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,164.66, add-ons for qualifying new technology services are included. If operating cost exceeds $52,306.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,474.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,135.61. The transfer operating threshold is the transfer adjustment factor * $7,164.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.98. The transfer capital threshold is the transfer adjustment factor * $532.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7773.72","7773.72","7787.69","1 through 10","6834.97","8054.5905","other","Inpatient DRG"
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","79494.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16671.2802","","Fee schedule rate ($135,334.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16671.2802","59413.47","59413.47","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","21768.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25799.59","","Standard inlier is a Case rate ($25,799.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,662.35) for the length of stay and the standard reimbursement.","25799.58","25799.58","25799.58","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","21768.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27713.90","","Standard inlier is a Case rate ($27,713.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,933.87) for the length of stay and the standard reimbursement.","26454.17","26454.17","27713.90","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","21768.56","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16671.2802","","Fee schedule rate ($32,441.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16671.2802","32441.68","32441.68","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Embolism,MINOR","134","DRG","","","","","","","","inpatient","","","14562.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14752.31","","Standard inlier is a Case rate ($14,752.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,736, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,094.03) for the length of stay and the standard reimbursement.","14752.30","14752.30","14752.30","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","23708.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14752.31","","Standard inlier is a Case rate ($14,752.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,736, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,094.03) for the length of stay and the standard reimbursement.","19210.65","19210.65","19210.65","1 through 10","4207.33","223299.37","case rate",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","100.17","414.21","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","189.00","141.75","MEDICARE [2001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","19","100.17","414.21","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","189.00","141.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","451.26","150.22","451.26","1 through 10","100.17","414.21","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.64","137.44","150.64","1 through 10","100.17","414.21","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","189.00","141.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.08","59.3","","107.82","107.82","107.82","1 through 10","84.01","268.39","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","148.27","78.45","","83.83","83.83","83.83","1 through 10","84.01","268.39","percent of total billed charges",""
"Pulse Ox Single Determination","PX-46000048","CDM","94760","CPT","0460","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","28.13","62.5","","10.35","10.35","10.35","1 through 10","20","35.06","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","176.45","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","MEDICARE [2001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","1 through 10","176.45","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.99","464.99","464.99","1 through 10","176.45","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","291.37","142.66","291.37","1 through 10","162.69","567.68","other","ASC "
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","291.77","145.89","291.77","1 through 10","162.69","567.68","other","ASC "
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.04","59.3","","208.62","208.62","208.62","1 through 10","162.69","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1243.98","1243.98","1243.98","1 through 10","162.69","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","162.69","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.13","78.45","","273.69","273.69","273.69","1 through 10","162.69","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","108.65","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MEDICARE [2001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","1 through 10","108.65","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.99","464.99","464.99","1 through 10","108.65","591.11","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.57","59.3","","208.62","208.62","208.62","1 through 10","91.12","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1243.98","1243.98","1243.98","1 through 10","91.12","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","91.12","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.82","78.45","","273.69","273.69","273.69","1 through 10","91.12","567.68","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","318.00","238.50","MEDICARE [2001]","HB NWH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","131.98","414.21","other","OPPS APC"
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","AETNA [1001]","HB CH AETNA HMO / PPO","2159.26","58.3","","464.71","67.87","1012.10","221","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2159.26","58.3","","293.04","293.04","293.04","11","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1962.96","53","","983.89","983.89","983.89","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2148.15","58","","677.18","677.18","677.18","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2314.81","62.5","","46.58","46.58","46.58","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2703.70","73","","747.15","747.15","747.15","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1646.29","44.45","","1141.67","481.21","1141.67","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1646.29","44.45","","76.54","76.54","76.54","1 through 10","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","WELLPOINT [1015]","HB CH WELLPOINT","2885.55","77.91","","273.64","94.28","1367.51","138","1646.29","2885.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2196.29","59.3","","720.78","230.14","2010.94","427","1851.85","2905.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2196.29","59.3","","344.45","344.45","344.45","1 through 10","1851.85","2905.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2905.55","78.45","","1120.13","1120.13","1120.13","1 through 10","1851.85","2905.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2905.55","78.45","","456.17","105.33","1284.66","242","1851.85","2905.55","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","AETNA [1001]","HB CH AETNA HMO / PPO","256.89","58.3","","2190.90","412.50","9264.59","16","195.86","343.3","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","255.57","58","","1903.20","1903.20","3826.66","1 through 10","195.86","343.3","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","275.40","62.5","","2186.25","2186.25","2186.25","32","195.86","343.3","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","321.67","73","","5556.60","5556.60","5556.60","1 through 10","195.86","343.3","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","WELLPOINT [1015]","HB CH WELLPOINT","343.30","77.91","","1955.15","885.83","3150.40","26","195.86","343.3","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","440.64","330.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","261.30","59.3","","831.03","253.22","2394.88","18","220.32","345.68","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","440.64","330.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","345.68","78.45","","2481.69","1563.74","8149.28","1 through 10","220.32","345.68","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","AETNA [1001]","HB CH AETNA HMO / PPO","1021.42","58.3","","464.71","67.87","1012.10","221","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1021.42","58.3","","293.04","293.04","293.04","11","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","928.56","53","","983.89","983.89","983.89","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1016.16","58","","677.18","677.18","677.18","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1095.00","62.5","","46.58","46.58","46.58","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1278.96","73","","747.15","747.15","747.15","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.76","44.45","","1141.67","481.21","1141.67","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.76","44.45","","76.54","76.54","76.54","1 through 10","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","WELLPOINT [1015]","HB CH WELLPOINT","1364.98","77.91","","273.64","94.28","1367.51","138","778.76","1364.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1038.94","59.3","","720.78","230.14","2010.94","427","876","1374.44","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1038.94","59.3","","344.45","344.45","344.45","1 through 10","876","1374.44","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1374.44","78.45","","1120.13","1120.13","1120.13","1 through 10","876","1374.44","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1374.44","78.45","","456.17","105.33","1284.66","242","876","1374.44","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","AETNA [1001]","HB CH AETNA HMO / PPO","4054.01","58.3","","464.71","67.87","1012.10","221","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4054.01","58.3","","293.04","293.04","293.04","11","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3685.46","53","","983.89","983.89","983.89","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4033.15","58","","677.18","677.18","677.18","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4346.06","62.5","","46.58","46.58","46.58","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5076.20","73","","747.15","747.15","747.15","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3090.92","44.45","","1141.67","481.21","1141.67","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3090.92","44.45","","76.54","76.54","76.54","1 through 10","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","WELLPOINT [1015]","HB CH WELLPOINT","5417.63","77.91","","273.64","94.28","1367.51","138","3090.92","5417.63","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","4123.54","59.3","","720.78","230.14","2010.94","427","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4123.54","59.3","","344.45","344.45","344.45","1 through 10","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5455.18","78.45","","1120.13","1120.13","1120.13","1 through 10","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5455.18","78.45","","456.17","105.33","1284.66","242","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","AETNA [1001]","HB CH AETNA HMO / PPO","566.12","58.3","","464.71","67.87","1012.10","221","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","566.12","58.3","","293.04","293.04","293.04","11","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","514.65","53","","983.89","983.89","983.89","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","563.20","58","","677.18","677.18","677.18","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","606.90","62.5","","46.58","46.58","46.58","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","708.86","73","","747.15","747.15","747.15","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.63","44.45","","1141.67","481.21","1141.67","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.63","44.45","","76.54","76.54","76.54","1 through 10","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","WELLPOINT [1015]","HB CH WELLPOINT","756.54","77.91","","273.64","94.28","1367.51","138","431.63","756.54","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","575.83","59.3","","720.78","230.14","2010.94","427","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","575.83","59.3","","344.45","344.45","344.45","1 through 10","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","761.78","78.45","","1120.13","1120.13","1120.13","1 through 10","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","761.78","78.45","","456.17","105.33","1284.66","242","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","AETNA [1001]","HB CH AETNA HMO / PPO","1028.76","58.3","","2190.90","412.50","9264.59","16","784.36","1374.8","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1023.47","58","","1903.20","1903.20","3826.66","1 through 10","784.36","1374.8","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1102.88","62.5","","2186.25","2186.25","2186.25","32","784.36","1374.8","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1288.16","73","","5556.60","5556.60","5556.60","1 through 10","784.36","1374.8","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","WELLPOINT [1015]","HB CH WELLPOINT","1374.80","77.91","","1955.15","885.83","3150.40","26","784.36","1374.8","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1764.60","1323.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1046.41","59.3","","831.03","253.22","2394.88","18","882.3","1384.33","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1764.60","1323.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1384.33","78.45","","2481.69","1563.74","8149.28","1 through 10","882.3","1384.33","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","AETNA [1001]","HB CH AETNA HMO / PPO","1311.75","58.3","","2190.90","412.50","9264.59","16","1000.13","1752.98","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1305.00","58","","1903.20","1903.20","3826.66","1 through 10","1000.13","1752.98","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1406.25","62.5","","2186.25","2186.25","2186.25","32","1000.13","1752.98","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1642.50","73","","5556.60","5556.60","5556.60","1 through 10","1000.13","1752.98","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","WELLPOINT [1015]","HB CH WELLPOINT","1752.98","77.91","","1955.15","885.83","3150.40","26","1000.13","1752.98","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","831.03","253.22","2394.88","18","1125","1765.13","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","2481.69","1563.74","8149.28","1 through 10","1125","1765.13","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","2190.90","412.50","9264.59","16","1778","3116.4","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","1903.20","1903.20","3826.66","1 through 10","1778","3116.4","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","2186.25","2186.25","2186.25","32","1778","3116.4","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","5556.60","5556.60","5556.60","1 through 10","1778","3116.4","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1955.15","885.83","3150.40","26","1778","3116.4","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","831.03","253.22","2394.88","18","2000","3138","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2481.69","1563.74","8149.28","1 through 10","2000","3138","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","2190.90","412.50","9264.59","16","2667","4674.6","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3480.00","58","","1903.20","1903.20","3826.66","1 through 10","2667","4674.6","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3750.00","62.5","","2186.25","2186.25","2186.25","32","2667","4674.6","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","5556.60","5556.60","5556.60","1 through 10","2667","4674.6","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","1955.15","885.83","3150.40","26","2667","4674.6","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","831.03","253.22","2394.88","18","3000","4707","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","2481.69","1563.74","8149.28","1 through 10","3000","4707","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","AETNA [1001]","HB CH AETNA HMO / PPO","3260.72","58.3","","464.71","67.87","1012.10","221","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3260.72","58.3","","293.04","293.04","293.04","11","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2964.29","53","","983.89","983.89","983.89","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3243.94","58","","677.18","677.18","677.18","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3495.63","62.5","","46.58","46.58","46.58","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4082.89","73","","747.15","747.15","747.15","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2486.09","44.45","","1141.67","481.21","1141.67","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2486.09","44.45","","76.54","76.54","76.54","1 through 10","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","both","","","5593.00","4194.75","WELLPOINT [1015]","HB CH WELLPOINT","4357.51","77.91","","273.64","94.28","1367.51","138","2486.09","4357.51","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5593.00","4194.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3316.65","59.3","","720.78","230.14","2010.94","427","2796.5","4387.71","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5593.00","4194.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3316.65","59.3","","344.45","344.45","344.45","1 through 10","2796.5","4387.71","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5593.00","4194.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4387.71","78.45","","1120.13","1120.13","1120.13","1 through 10","2796.5","4387.71","percent of total billed charges",""
"PUTTY GRAFT 1 TO 2MM 20 BONE ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5593.00","4194.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4387.71","78.45","","456.17","105.33","1284.66","242","2796.5","4387.71","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","AETNA [1001]","HB CH AETNA HMO / PPO","1596.07","58.3","","464.71","67.87","1012.10","221","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1596.07","58.3","","293.04","293.04","293.04","11","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1450.97","53","","983.89","983.89","983.89","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1587.85","58","","677.18","677.18","677.18","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1711.05","62.5","","46.58","46.58","46.58","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1998.51","73","","747.15","747.15","747.15","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.90","44.45","","1141.67","481.21","1141.67","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.90","44.45","","76.54","76.54","76.54","1 through 10","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","WELLPOINT [1015]","HB CH WELLPOINT","2132.93","77.91","","273.64","94.28","1367.51","138","1216.9","2132.93","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","1623.44","59.3","","720.78","230.14","2010.94","427","1368.84","2147.71","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1623.44","59.3","","344.45","344.45","344.45","1 through 10","1368.84","2147.71","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2147.71","78.45","","1120.13","1120.13","1120.13","1 through 10","1368.84","2147.71","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2147.71","78.45","","456.17","105.33","1284.66","242","1368.84","2147.71","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","AETNA [1001]","HB CH AETNA HMO / PPO","12826.00","58.3","","2190.90","412.50","9264.59","16","9779","17140.2","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","12760.00","58","","1903.20","1903.20","3826.66","1 through 10","9779","17140.2","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","13750.00","62.5","","2186.25","2186.25","2186.25","32","9779","17140.2","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16060.00","73","","5556.60","5556.60","5556.60","1 through 10","9779","17140.2","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","WELLPOINT [1015]","HB CH WELLPOINT","17140.20","77.91","","1955.15","885.83","3150.40","26","9779","17140.2","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","13046.00","59.3","","831.03","253.22","2394.88","18","11000","17259","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17259.00","78.45","","2481.69","1563.74","8149.28","1 through 10","11000","17259","percent of total billed charges",""
"Pyruvate","PX-30000660","CDM","84210","CPT","0301","RC","","","","both","","","92.00","69.00","AETNA [1001]","HB CH AETNA HMO / PPO","53.64","58.3","","50.46","50.46","50.46","1 through 10","14.19","87.4","percent of total billed charges",""
"Pyruvate","PX-30000660","CDM","84210","CPT","0301","RC","","","","outpatient","","","92.00","69.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.56","59.3","","52.15","44.50","52.15","1 through 10","11.19","72.17","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","AETNA [1001]","HB CH AETNA HMO / PPO","379.74","58.3","","293.13","293.13","460.31","1 through 10","289.53","1133.94","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","MEDICARE [2001]","HB NWH MEDICARE","313.68","","APC Price ($313.68).","312.03","312.03","327.78","23","289.53","1133.94","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.49","73","","440.95","440.95","440.95","1 through 10","289.53","1133.94","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","307.41","","APC Price ($313.68). Final payment is multiplied by 98%.","311.32","311.32","311.32","1 through 10","289.53","1133.94","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.53","44.45","","524.38","524.38","641.13","1 through 10","289.53","1133.94","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","651.36","488.52","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","307.41","","APC Price ($313.68). Final payment is multiplied by 98%.","305.79","305.79","305.79","1 through 10","289.53","1133.94","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","651.36","488.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","340.01","52.2","","266.24","265.51","266.24","38","325.68","609.17","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","651.36","488.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.99","78.45","","2018.64","515.56","2048.97","28","325.68","609.17","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","41","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","124.27","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","341.64","341.64","341.64","1 through 10","199.42","470.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","448.21","265.61","448.21","1 through 10","199.42","470.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","FALLON HEALTH [1008]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","378.87","378.87","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.56","124.56","124.56","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","24","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","124.16","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.60","124.07","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","outpatient","","","650.00","487.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","385.45","59.3","","370.35","370.35","370.35","1 through 10","199.42","509.93","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","outpatient","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","509.93","78.45","","485.88","485.88","485.88","1 through 10","199.42","509.93","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","782.00","586.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","782.00","586.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","756.8","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 1 View","PX-32000422","CDM","73501","CPT","0320","RC","","","","both","","","249.00","186.75","AETNA [1001]","HB CH AETNA HMO / PPO","145.17","58.3","","137.21","137.21","137.21","1 through 10","99.34","234.25","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","AETNA [1001]","HB CH AETNA HMO / PPO","226.20","58.3","","213.76","213.76","213.76","1 through 10","99.34","283.24","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","GENERIC COMMERCIAL [1009]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.59","97.59","97.59","1 through 10","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.18","99.18","99.18","1 through 10","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","50","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","outpatient","","","388.00","291.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","230.08","59.3","","518.02","518.02","518.02","1 through 10","110.42","304.39","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","outpatient","","","388.00","291.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","304.39","78.45","","143.29","143.29","143.29","1 through 10","110.42","304.39","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","both","","","482.00","361.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","124.07","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","366.00","274.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","435.00","326.25","CHAMPVA [160001]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","Tricare OPPS"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","435.00","326.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","252.58","1 through 10","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","247.88","247.88","247.88","1 through 10","193.36","341.26","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","AETNA [1001]","HB CH AETNA HMO / PPO","306.66","58.3","","289.74","289.74","289.74","1 through 10","119.97","756.8","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","14","119.97","756.8","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","142","119.97","756.8","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","372.48","11","119.97","756.8","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","124.27","16","119.97","756.8","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","526.00","394.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.92","59.3","","299.45","292.29","299.45","1 through 10","199.42","412.65","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","412.65","78.45","","392.86","232.81","392.86","1 through 10","199.42","412.65","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","291.83","78.45","","278.31","278.31","278.31","1 through 10","110.42","291.83","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","AETNA [1001]","HB CH AETNA HMO / PPO","3408.88","58.3","","1530.90","1160.93","1884.08","89","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3098.98","53","","5253.92","5253.92","5253.92","1 through 10","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3391.34","58","","12181.47","12181.47","12181.47","1 through 10","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3654.46","62.5","","1350.68","1350.68","1350.68","1 through 10","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2599.05","44.45","","1910.74","891.94","1910.74","1 through 10","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.14","4385.35","WELLPOINT [1015]","HB CH WELLPOINT","4555.51","77.91","","1829.79","1561.50","2617.12","88","2599.05","4555.51","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","3467.35","59.3","","1359.46","1201.30","1689.00","61","2923.57","4587.08","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3467.35","59.3","","1718.92","1718.92","1718.92","1 through 10","2923.57","4587.08","percent of total billed charges",""
"RADIAL HEAD W/ 19MM HD 6.5MM STM +3 HD HT STER","SUP-ITM-10322241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.14","4385.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4587.08","78.45","","1910.74","1019.06","2344.84","74","2923.57","4587.08","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","AETNA [1001]","HB CH AETNA HMO / PPO","2187.71","58.3","","464.71","67.87","1012.10","221","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2187.71","58.3","","293.04","293.04","293.04","11","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1988.83","53","","983.89","983.89","983.89","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2176.45","58","","677.18","677.18","677.18","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2345.31","62.5","","46.58","46.58","46.58","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2739.33","73","","747.15","747.15","747.15","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1667.99","44.45","","1141.67","481.21","1141.67","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1667.99","44.45","","76.54","76.54","76.54","1 through 10","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.50","2814.37","WELLPOINT [1015]","HB CH WELLPOINT","2923.57","77.91","","273.64","94.28","1367.51","138","1667.99","2923.57","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.50","2814.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2225.23","59.3","","720.78","230.14","2010.94","427","1876.25","2943.84","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.50","2814.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2225.23","59.3","","344.45","344.45","344.45","1 through 10","1876.25","2943.84","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.50","2814.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2943.84","78.45","","1120.13","1120.13","1120.13","1 through 10","1876.25","2943.84","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.50","2814.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2943.84","78.45","","456.17","105.33","1284.66","242","1876.25","2943.84","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","AETNA [1001]","HB CH AETNA HMO / PPO","147.50","58.3","","139.48","139.48","139.48","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","13","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","55","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.87","102.47","103.07","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","97.20","102.97","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","WELLPOINT [1015]","HB CH WELLPOINT","197.11","77.91","","193.75","193.75","246.00","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","253.00","189.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.03","59.3","","144.16","144.16","144.16","29","110.42","202.02","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.48","78.45","","189.12","112.08","358.08","20","110.42","202.02","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","AETNA [1001]","HB CH AETNA HMO / PPO","289.75","58.3","","273.86","273.86","273.86","1 through 10","119.97","423.04","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","28","119.97","423.04","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.77","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","WELLPOINT [1015]","HB CH WELLPOINT","387.21","77.91","","380.41","380.41","380.41","1 through 10","119.97","423.04","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","497.00","372.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","294.72","59.3","","283.04","283.04","283.04","15","199.42","389.9","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","389.90","78.45","","371.33","220.05","371.33","1 through 10","199.42","389.9","percent of total billed charges",""
"Radiologic Exam Abdomen 3+ Views","PX-32000438","CDM","74021","CPT","0320","RC","","","","both","","","506.00","379.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","148.90","216.03","23","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","110","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","ELDER SERVICES [1037]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.18","99.18","99.18","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","FALLON HEALTH [1008]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","313.68","313.68","313.68","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.87","102.87","102.87","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","HUMANA [1012]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.55","97.20","104.56","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1447","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","MOLINA [1014]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.45","207.45","207.45","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.16","73","","216.03","194.31","216.03","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TRICARE [160005]","HB NWH TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","305.41","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","99.18","104.56","1 through 10","99.34","305.41","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.87","97.60","307.41","213","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","99.18","104.56","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","173.58","292.91","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","139","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","WELLPOINT [1015]","HB CH WELLPOINT","305.41","77.91","","300.08","300.08","300.08","35","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","inpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.75","70.6","","292.91","173.58","292.91","1 through 10","219.52","276.75","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","223.27","168","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","173.58","292.91","136","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","484.00","363.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","377.08","other","OPPS APC"
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","484.00","363.00","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","377.08","other","OPPS APC"
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","608.00","456.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","473.69","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","158.76","158.76","158.76","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.59","97.59","102.89","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","24","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","210.24","73","","123.98","123.98","123.98","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","512.35","102.47","512.35","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","104.56","141.16","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","220.53","220.52","220.53","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","inpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","161.28","56","","154.81","154.81","154.81","1 through 10","161.28","203.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","217.48","164.08","583.26","31","110.42","225.94","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","206.26","127.57","215.26","13","110.42","225.94","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","AETNA [1001]","HB CH AETNA HMO / PPO","478.64","58.3","","452.47","452.47","452.47","1 through 10","200.84","758.54","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","217.73","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","217.74","217.54","217.74","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","86","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","TRICARE [160005]","HB NWH TRICARE","200.84","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","211.41","211.41","1 through 10","200.84","758.54","other","Tricare OPPS"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.58","207.18","207.78","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","207.18","207.69","11","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","WELLPOINT [1015]","HB CH WELLPOINT","639.64","77.91","","628.50","628.50","628.50","1 through 10","200.84","758.54","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","821.00","615.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","486.85","59.3","","467.63","467.63","467.63","1 through 10","309.54","644.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","644.07","78.45","","613.51","363.57","613.51","1 through 10","309.54","644.07","percent of total billed charges",""
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","156.37","156.37","156.37","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","outpatient","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","367.15","78.45","","349.80","349.80","349.80","1 through 10","208.03","367.15","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","AETNA [1001]","HB CH AETNA HMO / PPO","1214.63","58.3","","464.71","67.87","1012.10","221","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1214.63","58.3","","293.04","293.04","293.04","11","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1104.21","53","","983.89","983.89","983.89","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1208.38","58","","677.18","677.18","677.18","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1302.13","62.5","","46.58","46.58","46.58","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1520.89","73","","747.15","747.15","747.15","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.08","44.45","","1141.67","481.21","1141.67","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.08","44.45","","76.54","76.54","76.54","1 through 10","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","WELLPOINT [1015]","HB CH WELLPOINT","1623.18","77.91","","273.64","94.28","1367.51","138","926.08","1623.18","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1235.46","59.3","","720.78","230.14","2010.94","427","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1235.46","59.3","","344.45","344.45","344.45","1 through 10","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1634.44","78.45","","1120.13","1120.13","1120.13","1 through 10","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1634.44","78.45","","456.17","105.33","1284.66","242","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","AETNA [1001]","HB CH AETNA HMO / PPO","869.10","58.3","","464.71","67.87","1012.10","221","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","869.10","58.3","","293.04","293.04","293.04","11","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","790.09","53","","983.89","983.89","983.89","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","864.62","58","","677.18","677.18","677.18","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","931.71","62.5","","46.58","46.58","46.58","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1088.23","73","","747.15","747.15","747.15","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.63","44.45","","1141.67","481.21","1141.67","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.63","44.45","","76.54","76.54","76.54","1 through 10","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1490.73","1118.05","WELLPOINT [1015]","HB CH WELLPOINT","1161.43","77.91","","273.64","94.28","1367.51","138","662.63","1161.43","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1490.73","1118.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","884.00","59.3","","720.78","230.14","2010.94","427","745.37","1169.48","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1490.73","1118.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","884.00","59.3","","344.45","344.45","344.45","1 through 10","745.37","1169.48","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1490.73","1118.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1169.48","78.45","","1120.13","1120.13","1120.13","1 through 10","745.37","1169.48","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1490.73","1118.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1169.48","78.45","","456.17","105.33","1284.66","242","745.37","1169.48","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","AETNA [1001]","HB CH AETNA HMO / PPO","1037.09","58.3","","464.71","67.87","1012.10","221","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1037.09","58.3","","293.04","293.04","293.04","11","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","942.81","53","","983.89","983.89","983.89","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1031.75","58","","677.18","677.18","677.18","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1111.80","62.5","","46.58","46.58","46.58","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1298.58","73","","747.15","747.15","747.15","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.71","44.45","","1141.67","481.21","1141.67","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.71","44.45","","76.54","76.54","76.54","1 through 10","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","WELLPOINT [1015]","HB CH WELLPOINT","1385.93","77.91","","273.64","94.28","1367.51","138","790.71","1385.93","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","1054.88","59.3","","720.78","230.14","2010.94","427","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1054.88","59.3","","344.45","344.45","344.45","1 through 10","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1395.53","78.45","","1120.13","1120.13","1120.13","1 through 10","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 4 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION ARTICULAR VOLAR DISTAL RT","SUP-ITM-10023229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1395.53","78.45","","456.17","105.33","1284.66","242","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","AETNA [1001]","HB CH AETNA HMO / PPO","938.58","58.3","","464.71","67.87","1012.10","221","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","938.58","58.3","","293.04","293.04","293.04","11","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","853.26","53","","983.89","983.89","983.89","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","933.75","58","","677.18","677.18","677.18","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1006.20","62.5","","46.58","46.58","46.58","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1175.24","73","","747.15","747.15","747.15","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","715.61","44.45","","1141.67","481.21","1141.67","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","715.61","44.45","","76.54","76.54","76.54","1 through 10","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","WELLPOINT [1015]","HB CH WELLPOINT","1254.29","77.91","","273.64","94.28","1367.51","138","715.61","1254.29","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","954.68","59.3","","720.78","230.14","2010.94","427","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","954.68","59.3","","344.45","344.45","344.45","1 through 10","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1262.98","78.45","","1120.13","1120.13","1120.13","1 through 10","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1262.98","78.45","","456.17","105.33","1284.66","242","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","AETNA [1001]","HB CH AETNA HMO / PPO","1262.80","58.3","","464.71","67.87","1012.10","221","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1262.80","58.3","","293.04","293.04","293.04","11","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1148.00","53","","983.89","983.89","983.89","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1256.30","58","","677.18","677.18","677.18","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1353.77","62.5","","46.58","46.58","46.58","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1581.20","73","","747.15","747.15","747.15","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","962.80","44.45","","1141.67","481.21","1141.67","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","962.80","44.45","","76.54","76.54","76.54","1 through 10","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","WELLPOINT [1015]","HB CH WELLPOINT","1687.55","77.91","","273.64","94.28","1367.51","138","962.8","1687.55","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","1284.46","59.3","","720.78","230.14","2010.94","427","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1284.46","59.3","","344.45","344.45","344.45","1 through 10","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1699.25","78.45","","1120.13","1120.13","1120.13","1 through 10","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1699.25","78.45","","456.17","105.33","1284.66","242","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","AETNA [1001]","HB CH AETNA HMO / PPO","990.48","58.3","","464.71","67.87","1012.10","221","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","990.48","58.3","","293.04","293.04","293.04","11","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","900.43","53","","983.89","983.89","983.89","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","985.38","58","","677.18","677.18","677.18","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1061.83","62.5","","46.58","46.58","46.58","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1240.22","73","","747.15","747.15","747.15","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.17","44.45","","1141.67","481.21","1141.67","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.17","44.45","","76.54","76.54","76.54","1 through 10","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","WELLPOINT [1015]","HB CH WELLPOINT","1323.64","77.91","","273.64","94.28","1367.51","138","755.17","1323.64","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1007.47","59.3","","720.78","230.14","2010.94","427","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1007.47","59.3","","344.45","344.45","344.45","1 through 10","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1332.81","78.45","","1120.13","1120.13","1120.13","1 through 10","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1332.81","78.45","","456.17","105.33","1284.66","242","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","AETNA [1001]","HB CH AETNA HMO / PPO","1053.88","58.3","","464.71","67.87","1012.10","221","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1053.88","58.3","","293.04","293.04","293.04","11","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.07","53","","983.89","983.89","983.89","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1048.45","58","","677.18","677.18","677.18","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1129.80","62.5","","46.58","46.58","46.58","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1319.61","73","","747.15","747.15","747.15","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.51","44.45","","1141.67","481.21","1141.67","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.51","44.45","","76.54","76.54","76.54","1 through 10","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","WELLPOINT [1015]","HB CH WELLPOINT","1408.36","77.91","","273.64","94.28","1367.51","138","803.51","1408.36","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","1071.95","59.3","","720.78","230.14","2010.94","427","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1071.95","59.3","","344.45","344.45","344.45","1 through 10","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1418.12","78.45","","1120.13","1120.13","1120.13","1 through 10","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.12","78.45","","456.17","105.33","1284.66","242","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","AETNA [1001]","HB CH AETNA HMO / PPO","931.22","58.3","","464.71","67.87","1012.10","221","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","931.22","58.3","","293.04","293.04","293.04","11","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","846.56","53","","983.89","983.89","983.89","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","926.43","58","","677.18","677.18","677.18","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","998.31","62.5","","46.58","46.58","46.58","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1166.02","73","","747.15","747.15","747.15","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","710.00","44.45","","1141.67","481.21","1141.67","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","710.00","44.45","","76.54","76.54","76.54","1 through 10","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1597.29","1197.97","WELLPOINT [1015]","HB CH WELLPOINT","1244.45","77.91","","273.64","94.28","1367.51","138","710","1244.45","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1597.29","1197.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","947.19","59.3","","720.78","230.14","2010.94","427","798.65","1253.07","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1597.29","1197.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","947.19","59.3","","344.45","344.45","344.45","1 through 10","798.65","1253.07","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1597.29","1197.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1253.07","78.45","","1120.13","1120.13","1120.13","1 through 10","798.65","1253.07","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1597.29","1197.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1253.07","78.45","","456.17","105.33","1284.66","242","798.65","1253.07","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","AETNA [1001]","HB CH AETNA HMO / PPO","1698.28","58.3","","1530.90","1160.93","1884.08","89","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.89","53","","5253.92","5253.92","5253.92","1 through 10","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1689.54","58","","12181.47","12181.47","12181.47","1 through 10","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1820.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.83","44.45","","1910.74","891.94","1910.74","1 through 10","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","WELLPOINT [1015]","HB CH WELLPOINT","2269.52","77.91","","1829.79","1561.50","2617.12","88","1294.83","2269.52","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1727.41","59.3","","1359.46","1201.30","1689.00","61","1456.5","2285.25","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1727.41","59.3","","1718.92","1718.92","1718.92","1 through 10","1456.5","2285.25","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2285.25","78.45","","1910.74","1019.06","2344.84","74","1456.5","2285.25","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","AETNA [1001]","HB CH AETNA HMO / PPO","1721.02","58.3","","464.71","67.87","1012.10","221","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1721.02","58.3","","293.04","293.04","293.04","11","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1564.56","53","","983.89","983.89","983.89","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1712.16","58","","677.18","677.18","677.18","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1845.00","62.5","","46.58","46.58","46.58","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2154.96","73","","747.15","747.15","747.15","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1312.16","44.45","","1141.67","481.21","1141.67","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1312.16","44.45","","76.54","76.54","76.54","1 through 10","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","WELLPOINT [1015]","HB CH WELLPOINT","2299.90","77.91","","273.64","94.28","1367.51","138","1312.16","2299.9","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1750.54","59.3","","720.78","230.14","2010.94","427","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1750.54","59.3","","344.45","344.45","344.45","1 through 10","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2315.84","78.45","","1120.13","1120.13","1120.13","1 through 10","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2315.84","78.45","","456.17","105.33","1284.66","242","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","AETNA [1001]","HB CH AETNA HMO / PPO","953.87","58.3","","464.71","67.87","1012.10","221","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","953.87","58.3","","293.04","293.04","293.04","11","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","867.15","53","","983.89","983.89","983.89","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","948.96","58","","677.18","677.18","677.18","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1022.59","62.5","","46.58","46.58","46.58","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1194.38","73","","747.15","747.15","747.15","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","727.26","44.45","","1141.67","481.21","1141.67","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","727.26","44.45","","76.54","76.54","76.54","1 through 10","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1636.14","1227.10","WELLPOINT [1015]","HB CH WELLPOINT","1274.72","77.91","","273.64","94.28","1367.51","138","727.26","1274.72","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1636.14","1227.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","970.23","59.3","","720.78","230.14","2010.94","427","818.07","1283.55","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1636.14","1227.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","970.23","59.3","","344.45","344.45","344.45","1 through 10","818.07","1283.55","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1636.14","1227.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1283.55","78.45","","1120.13","1120.13","1120.13","1 through 10","818.07","1283.55","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1636.14","1227.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1283.55","78.45","","456.17","105.33","1284.66","242","818.07","1283.55","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","AETNA [1001]","HB CH AETNA HMO / PPO","2025.93","58.3","","464.71","67.87","1012.10","221","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2025.93","58.3","","293.04","293.04","293.04","11","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1841.75","53","","983.89","983.89","983.89","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2015.50","58","","677.18","677.18","677.18","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2171.88","62.5","","46.58","46.58","46.58","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2536.75","73","","747.15","747.15","747.15","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1544.64","44.45","","1141.67","481.21","1141.67","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1544.64","44.45","","76.54","76.54","76.54","1 through 10","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","WELLPOINT [1015]","HB CH WELLPOINT","2707.37","77.91","","273.64","94.28","1367.51","138","1544.64","2707.37","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2060.68","59.3","","720.78","230.14","2010.94","427","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2060.68","59.3","","344.45","344.45","344.45","1 through 10","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2726.14","78.45","","1120.13","1120.13","1120.13","1 through 10","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD LEFT","SUP-ITM-10092387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2726.14","78.45","","456.17","105.33","1284.66","242","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","AETNA [1001]","HB CH AETNA HMO / PPO","2261.02","58.3","","464.71","67.87","1012.10","221","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2261.02","58.3","","293.04","293.04","293.04","11","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2055.47","53","","983.89","983.89","983.89","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2249.39","58","","677.18","677.18","677.18","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2423.91","62.5","","46.58","46.58","46.58","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2831.12","73","","747.15","747.15","747.15","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.88","44.45","","1141.67","481.21","1141.67","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.88","44.45","","76.54","76.54","76.54","1 through 10","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","WELLPOINT [1015]","HB CH WELLPOINT","3021.54","77.91","","273.64","94.28","1367.51","138","1723.88","3021.54","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2299.80","59.3","","720.78","230.14","2010.94","427","1939.13","3042.49","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2299.80","59.3","","344.45","344.45","344.45","1 through 10","1939.13","3042.49","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3042.49","78.45","","1120.13","1120.13","1120.13","1 through 10","1939.13","3042.49","percent of total billed charges",""
"RADIUS PLATE DISTAL VARIAX VOLAR 8 HOLE RT NARROW XSHORT","SUP-ITM-10186194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3042.49","78.45","","456.17","105.33","1284.66","242","1939.13","3042.49","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","AETNA [1001]","HB CH AETNA HMO / PPO","2256.21","58.3","","464.71","67.87","1012.10","221","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2256.21","58.3","","293.04","293.04","293.04","11","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2051.10","53","","983.89","983.89","983.89","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2244.60","58","","677.18","677.18","677.18","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2418.75","62.5","","46.58","46.58","46.58","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2825.10","73","","747.15","747.15","747.15","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.22","44.45","","1141.67","481.21","1141.67","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.22","44.45","","76.54","76.54","76.54","1 through 10","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","WELLPOINT [1015]","HB CH WELLPOINT","3015.12","77.91","","273.64","94.28","1367.51","138","1720.22","3015.12","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.91","59.3","","720.78","230.14","2010.94","427","1935","3036.02","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2294.91","59.3","","344.45","344.45","344.45","1 through 10","1935","3036.02","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3036.02","78.45","","1120.13","1120.13","1120.13","1 through 10","1935","3036.02","percent of total billed charges",""
"RADIUS PLATE PEG 10 HOLE RIGHT","SUP-ITM-10100631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3036.02","78.45","","456.17","105.33","1284.66","242","1935","3036.02","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","AETNA [1001]","HB CH AETNA HMO / PPO","1696.53","58.3","","464.71","67.87","1012.10","221","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1696.53","58.3","","293.04","293.04","293.04","11","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1542.30","53","","983.89","983.89","983.89","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1687.80","58","","677.18","677.18","677.18","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1818.75","62.5","","46.58","46.58","46.58","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2124.30","73","","747.15","747.15","747.15","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1293.50","44.45","","1141.67","481.21","1141.67","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1293.50","44.45","","76.54","76.54","76.54","1 through 10","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","both","","","2910.00","2182.50","WELLPOINT [1015]","HB CH WELLPOINT","2267.18","77.91","","273.64","94.28","1367.51","138","1293.5","2267.18","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1725.63","59.3","","720.78","230.14","2010.94","427","1455","2282.9","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1725.63","59.3","","344.45","344.45","344.45","1 through 10","1455","2282.9","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2282.90","78.45","","1120.13","1120.13","1120.13","1 through 10","1455","2282.9","percent of total billed charges",""
"RADIUS PLATE PEG 7 HOLE LEFT","SUP-ITM-10093661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2910.00","2182.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2282.90","78.45","","456.17","105.33","1284.66","242","1455","2282.9","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","AETNA [1001]","HB CH AETNA HMO / PPO","2075.29","58.3","","464.71","67.87","1012.10","221","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2075.29","58.3","","293.04","293.04","293.04","11","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1886.63","53","","983.89","983.89","983.89","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2064.61","58","","677.18","677.18","677.18","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2224.80","62.5","","46.58","46.58","46.58","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2598.57","73","","747.15","747.15","747.15","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1582.28","44.45","","1141.67","481.21","1141.67","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1582.28","44.45","","76.54","76.54","76.54","1 through 10","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","WELLPOINT [1015]","HB CH WELLPOINT","2773.35","77.91","","273.64","94.28","1367.51","138","1582.28","2773.35","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","2110.89","59.3","","720.78","230.14","2010.94","427","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2110.89","59.3","","344.45","344.45","344.45","1 through 10","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2792.57","78.45","","1120.13","1120.13","1120.13","1 through 10","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2792.57","78.45","","456.17","105.33","1284.66","242","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","AETNA [1001]","HB CH AETNA HMO / PPO","1224.37","58.3","","464.71","67.87","1012.10","221","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.37","58.3","","293.04","293.04","293.04","11","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.06","53","","983.89","983.89","983.89","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.07","58","","677.18","677.18","677.18","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.58","62.5","","46.58","46.58","46.58","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.09","73","","747.15","747.15","747.15","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.50","44.45","","1141.67","481.21","1141.67","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.50","44.45","","76.54","76.54","76.54","1 through 10","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","WELLPOINT [1015]","HB CH WELLPOINT","1636.20","77.91","","273.64","94.28","1367.51","138","933.5","1636.2","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.37","59.3","","720.78","230.14","2010.94","427","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.37","59.3","","344.45","344.45","344.45","1 through 10","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1647.54","78.45","","1120.13","1120.13","1120.13","1 through 10","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.54","78.45","","456.17","105.33","1284.66","242","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","AETNA [1001]","HB CH AETNA HMO / PPO","1284.08","58.3","","464.71","67.87","1012.10","221","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1284.08","58.3","","293.04","293.04","293.04","11","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1167.35","53","","983.89","983.89","983.89","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1277.47","58","","677.18","677.18","677.18","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1376.59","62.5","","46.58","46.58","46.58","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1607.85","73","","747.15","747.15","747.15","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","979.03","44.45","","1141.67","481.21","1141.67","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","979.03","44.45","","76.54","76.54","76.54","1 through 10","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","WELLPOINT [1015]","HB CH WELLPOINT","1716.00","77.91","","273.64","94.28","1367.51","138","979.03","1716","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","1306.11","59.3","","720.78","230.14","2010.94","427","1101.27","1727.89","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1306.11","59.3","","344.45","344.45","344.45","1 through 10","1101.27","1727.89","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1727.89","78.45","","1120.13","1120.13","1120.13","1 through 10","1101.27","1727.89","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1727.89","78.45","","456.17","105.33","1284.66","242","1101.27","1727.89","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","462","5.12","58.9","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","TRICARE [160005]","HB NWH TRICARE","58.90","95","","6.29","6.29","6.29","12","5.12","58.9","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","26","5.12","58.9","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","105.48","382","5.39","48.64","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","27.34","46.13","324","5.39","48.64","percent of total billed charges",""
"Rast Allergen Igg Qn Sq Ea","PX-30000774","CDM","86001","CPT","0302","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.58","34.57","276.59","1 through 10","5.39","47.85","percent of total billed charges",""
"Rast Allergen Igg Qn Sq Ea","PX-30000774","CDM","86001","CPT","0302","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","26.88","26.88","26.88","1 through 10","5.39","47.85","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0300","RC","","","","inpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","128.80","56","","131.26","131.26","131.26","1 through 10","128.8","162.38","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","127.01","127.01","254.02","1 through 10","102.24","1456.11","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","420.35","420.35","1 through 10","102.24","1456.11","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","MEDICARE [2001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","392.31","427.19","1 through 10","102.24","1456.11","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","TRICARE [160005]","HB NWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","405.83","405.83","405.83","1 through 10","102.24","1456.11","other","Tricare OPPS"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","1255.95","14","102.24","1456.11","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","131.26","131.26","393.78","1 through 10","115","926.86","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","172.21","102.05","172.21","1 through 10","115","926.86","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0300","RC","","","","inpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.44","56","","84.97","84.97","84.97","1 through 10","83.44","105.19","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0300","RC","","","","inpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.19","70.6","","111.48","66.06","111.48","1 through 10","83.44","105.19","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","280","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","65.35","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","145.00","145.00","145.00","1 through 10","60.28","270.7","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","108.77","73","","80.08","80.08","82.22","1 through 10","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","TRICARE [160005]","HB NWH TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","145.00","145.00","145.00","1 through 10","60.28","270.7","other","Tricare OPPS"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.23","44.45","","111.48","66.06","111.48","1 through 10","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","WELLPOINT [1015]","HB CH WELLPOINT","116.09","77.91","","114.20","114.20","259.20","42","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","84.97","84.97","99.02","246","74.5","172.31","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","111.48","66.06","111.48","203","74.5","172.31","percent of total billed charges",""
"RBC Pretreatment Absorption","PX-30000104","CDM","86978","CPT","0302","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","104.31","1 through 10","18.5","143.56","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","464.71","67.87","1012.10","221","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","293.04","293.04","293.04","11","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","983.89","983.89","983.89","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","139.20","58","","677.18","677.18","677.18","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","150.00","62.5","","46.58","46.58","46.58","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","747.15","747.15","747.15","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","1141.67","481.21","1141.67","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","76.54","76.54","76.54","1 through 10","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","273.64","94.28","1367.51","138","106.68","186.98","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","720.78","230.14","2010.94","427","120","188.28","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","142.32","59.3","","344.45","344.45","344.45","1 through 10","120","188.28","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","1120.13","1120.13","1120.13","1 through 10","120","188.28","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","456.17","105.33","1284.66","242","120","188.28","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","7130.77","5348.08","WELLPOINT [1015]","HB CH WELLPOINT","5555.58","77.91","","7088.40","7088.40","7088.40","1 through 10","3779.31","5555.58","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","7130.77","5348.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","4228.55","59.3","","5274.00","5148.00","5274.00","1 through 10","3169.63","5594.09","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","7130.77","5348.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5594.09","78.45","","6919.20","6919.20","6919.20","1 through 10","3169.63","5594.09","percent of total billed charges",""
"Rectal Resection With Cc","333","MS-DRG","","","","","","","","inpatient","","","55598.15","41698.61","MEDICARE [2001]","HB NWH MEDICARE","20292.66","","Case rate ($20,292.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,846.06, add-ons for qualifying new technology services are included. If operating cost exceeds $65,988.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,492.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $18,741.90. The transfer operating threshold is the transfer adjustment factor * $20,846.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,550.74. The transfer capital threshold is the transfer adjustment factor * $1,550.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20320.69","20320.69","20320.69","1 through 10","19886.81","24042.68","other","Inpatient Replacement Plans DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","28481.44","21361.08","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","12531.75","","Case rate ($12,166.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,498.56, add-ons for qualifying new technology services are included. If operating cost exceeds $57,640.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,871.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,236.98. The transfer operating threshold is the transfer adjustment factor * $12,498.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.77. The transfer capital threshold is the transfer adjustment factor * $929.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12591.92","12591.92","12639.15","1 through 10","11923.42","13912.8341","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","28481.44","21361.08","MEDICARE [2001]","HB NWH MEDICARE","13377.65","","Case rate ($13,377.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,498.56, add-ons for qualifying new technology services are included. If operating cost exceeds $57,640.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,871.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,447.88. The transfer operating threshold is the transfer adjustment factor * $12,498.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.77. The transfer capital threshold is the transfer adjustment factor * $929.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13427.69","762.69","13451.83","31","11923.42","13912.8341","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","28481.44","21361.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11923.42","","Case rate ($12,166.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,498.56, add-ons for qualifying new technology services are included. If operating cost exceeds $57,640.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,871.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,236.98. The transfer operating threshold is the transfer adjustment factor * $12,498.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.77. The transfer capital threshold is the transfer adjustment factor * $929.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12012.31","12012.31","12012.31","1 through 10","11923.42","13912.8341","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","28481.44","21361.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","11923.42","","Case rate ($12,166.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,498.56, add-ons for qualifying new technology services are included. If operating cost exceeds $57,640.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,871.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,236.98. The transfer operating threshold is the transfer adjustment factor * $12,498.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.77. The transfer capital threshold is the transfer adjustment factor * $929.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12240.76","12240.76","14670.56","1 through 10","11923.42","13912.8341","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","21880.09","16410.07","MEDICARE [2001]","HB NWH MEDICARE","8746.96","","Case rate ($8,746.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,172.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,314.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,549.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,139.03. The transfer operating threshold is the transfer adjustment factor * $8,172.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.93. The transfer capital threshold is the transfer adjustment factor * $607.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8808.32","8808.20","8824.14","29","7796.12","9425.32","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","21880.09","16410.07","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7796.12","","Case rate ($7,955.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,172.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,314.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,549.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,347.29. The transfer operating threshold is the transfer adjustment factor * $8,172.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.93. The transfer capital threshold is the transfer adjustment factor * $607.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7891.10","7891.10","7891.10","1 through 10","7796.12","9425.32","other","Inpatient DRG"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","755.09","63.4","","850.51","850.51","850.51","1 through 10","172.9","1132.64","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","MEDICARE [2001]","HB NWH MEDICARE","182.00","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.00","182.00","182.00","30","172.9","1132.64","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","869.43","73","","1285.92","642.96","1285.92","1 through 10","172.9","1132.64","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","178.36","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.40","177.20","354.40","1 through 10","172.9","1132.64","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","178.36","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","178.36","178.36","178.36","1 through 10","172.9","1132.64","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1191.00","893.25","WELLPOINT [1015]","HB CH WELLPOINT","927.91","77.91","","912.04","912.04","912.04","1 through 10","172.9","1132.64","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1191.00","893.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","706.26","59.3","","1034.41","1034.41","1034.41","1 through 10","327.53","934.34","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1191.00","893.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","687.21","57.7","","554.34","184.78","554.34","1 through 10","327.53","934.34","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1191.00","893.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","934.34","78.45","","890.27","527.58","890.27","1 through 10","327.53","934.34","percent of total billed charges",""
"Rem FB Muscle/Tendon Cplx","PX-76000284","CDM","20525","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","7178","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","AETNA [1001]","HB CH AETNA HMO / PPO","3404.72","58.3","","4806.46","2343.98","5990.92","1 through 10","2378.29","4549.94","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6136.76","6136.76","6136.76","1 through 10","2378.29","4549.94","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5299.15","5299.15","5299.15","1 through 10","2378.29","4549.94","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB NWH MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3101.27","3398.86","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2378.29","4549.94","per diem",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","3567.01","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","10008.84","10008.84","10008.84","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3330.54","","APC Price ($3,398.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3338.39","3337.89","3338.39","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","WELLPOINT [1015]","HB CH WELLPOINT","4549.94","77.91","","10131.69","10131.69","10131.69","1 through 10","2378.29","4549.94","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3845.67","1922.84","3927.26","1 through 10","2378.29","4581.48","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2378.29","4581.48","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3932.70","3851.11","3932.70","22","2378.29","4581.48","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5588.98","5374.94","23595.38","16","2378.29","4581.48","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","9371.13","5874.38","9371.13","1 through 10","2378.29","4581.48","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.48","78.45","","6889.22","2719.93","15189.95","1 through 10","2378.29","4581.48","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5660.33","5660.33","5660.33","1 through 10","2378.29","4581.48","other","Multiple Surgery"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","AETNA [1001]","HB CH AETNA HMO / PPO","345.72","58.3","","327.16","327.16","327.16","1 through 10","42.07","462.01","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","45.56","42.36","46.46","102","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","77","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","HUMANA [1012]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.66","40.37","44.28","20","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","MEDICARE [2001]","HB NWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1615","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.59","40.74","43.79","119","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.58","41.16","43.90","170","42.07","462.01","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","593.00","444.75","WELLPOINT [1015]","HB CH WELLPOINT","462.01","77.91","","454.45","454.45","454.45","48","42.07","462.01","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","593.00","444.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","351.65","59.3","","338.12","338.12","338.12","35","63.28","465.21","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","593.00","444.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.21","78.45","","443.60","443.60","443.60","57","63.28","465.21","percent of total billed charges",""
"Rem Pericatheter Mat Cv Device","PX-76001111","CDM","36595","CPT","0761","RC","","","","both","","","6468.00","4851.00","MEDICARE [2001]","HB NWH MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2377.37","5039.22","other","OPPS APC"
"Rem Pericatheter Mat Cv Device","PX-76001111","CDM","36595","CPT","0761","RC","","","","outpatient","","","6468.00","4851.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4367.98","4367.98","4367.98","1 through 10","2377.37","7178","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","AETNA [1001]","HB CH AETNA HMO / PPO","1582.85","58.3","","1496.88","1496.88","1496.88","1 through 10","620.01","2115.26","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1899.96","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1905.30","1905.30","1905.30","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","911.42","911.42","911.42","1 through 10","620.01","2115.26","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1605.83","1605.83","1605.83","1 through 10","620.01","2115.26","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","20","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","620.01","2115.26","per diem",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","MOLINA [1014]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3660.08","3660.08","3660.08","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1981.95","73","","1514.90","1514.90","1514.90","1 through 10","620.01","2115.26","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5445.90","1815.70","5445.90","14","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1844.80","1807.90","1844.80","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","WELLPOINT [1015]","HB CH WELLPOINT","2115.26","77.91","","2079.26","2079.26","2079.26","1 through 10","620.01","2115.26","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1002.55","1002.55","1023.82","1 through 10","620.01","2129.92","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1025.24","512.62","1025.24","20","620.01","2129.92","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1610.00","59.3","","1547.04","1547.04","1547.04","1 through 10","620.01","2129.92","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1457.02","1457.02","2802.44","12","620.01","2129.92","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1531.42","1531.42","1531.42","1 through 10","620.01","2129.92","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2129.92","78.45","","2029.63","1589.11","2029.63","1 through 10","620.01","2129.92","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","MEDICARE [2001]","HB NWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","685.64","734.22","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1025.24","1025.24","1025.24","1 through 10","620.01","1226.96","other","ASC "
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","463.24","463.24","463.24","1 through 10","360.36","1354.34","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","360.36","1354.34","per diem",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","outpatient","","","840.00","630.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","287.86","287.86","287.86","1 through 10","398.14","859.96","other","ASC "
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3969.00","3969.00","3969.00","1 through 10","1855","2726.85","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","2051.00","2051.00","2051.00","1 through 10","1555.75","2745.75","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1813.99","1594.60","2690.80","1 through 10","1555.75","2745.75","percent of total billed charges",""
"Removal Anal Seton Other Marker","PX-75000210","CDM","46030","CPT","0750","RC","","","","both","","","1592.00","1194.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","682.97","1240.33","per diem",""
"Removal Anal Seton Other Marker","PX-75000210","CDM","46030","CPT","0750","RC","","","","both","","","1592.00","1194.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","682.97","1240.33","per diem",""
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","508.00","381.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","690.91","690.91","690.91","1 through 10","269.24","1146.7","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","508.00","381.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","973.53","1095.60","1 through 10","269.24","1146.7","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","508.00","381.00","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","1 through 10","269.24","1146.7","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","508.00","381.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1095.60","1092.14","1098.54","1 through 10","269.24","1146.7","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","508.00","381.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","1231.42","1231.42","1 through 10","225.81","1873.9","other","ASC "
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","508.00","381.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","1789.64","1789.64","1 through 10","225.81","1873.9","other","Multiple Surgery"
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","72.00","54.00","WELLPOINT [1015]","HB CH WELLPOINT","56.10","77.91","","55.13","55.13","55.13","1 through 10","38.16","217.45","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat|BILATERAL PROCEDURE","PX-76002197","CDM","69209","CPT","0761","RC","","","50","outpatient","","","72.00","54.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","138.64","67.89","138.64","1 through 10","95.88","527.92","other","ASC "
"Removal Intact Breast Implant|BILATERAL PROCEDURE","PX-76000265","CDM","19328","CPT","0761","RC","","","50","both","","","9410.00","7057.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,815.50). Procedure 2, Per diem ($1,407.75). Procedures 3 - 9999, Per diem ($703.88).","2815.50","2815.50","2815.50","1 through 10","","","per diem",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","both","","","463.00","347.25","AETNA [1001]","HB CH AETNA HMO / PPO","269.93","58.3","","4602.91","4602.91","4602.91","1 through 10","245.39","1354.34","percent of total billed charges",""
"Removal of Anal Fissure","PX-75000455","CDM","46200","CPT","0750","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1857.71","50.1","","3780.34","3780.34","3780.34","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Removal of Hydrocele,Tunica,Unilat","PX-76002809","CDM","55040","CPT","0761","RC","","","","both","","","7761.00","5820.75","AETNA [1001]","HB CH AETNA HMO / PPO","4524.66","58.3","","1996.97","1996.97","1996.97","1 through 10","3329.47","6046.6","percent of total billed charges",""
"Removal of Hydrocele,Tunica,Unilat","PX-76002809","CDM","55040","CPT","0761","RC","","","","both","","","7761.00","5820.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","3329.47","6046.6","per diem",""
"Removal of Hydrocele,Tunica,Unilat","PX-76002809","CDM","55040","CPT","0761","RC","","","","outpatient","","","7761.00","5820.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3888.26","50.1","","4772.53","2436.82","4772.53","1 through 10","3104.4","6088.5","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2193.00","1644.75","MEDICARE [2001]","HB NWH MEDICARE","835.47","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","11","579.34","1708.57","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2193.00","1644.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1404.20","1702.00","1 through 10","579.34","1708.57","per diem",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2193.00","1644.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.25","826.25","826.25","1 through 10","579.34","1708.57","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2193.00","1644.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","820.85","755.62","820.85","1 through 10","579.34","1708.57","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","956.66","936.79","956.66","1 through 10","579.34","1873.9","other","ASC "
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","957.99","957.99","1 through 10","579.34","1873.9","other","ASC "
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1300.45","59.3","","1249.35","1249.35","1249.35","1 through 10","579.34","1873.9","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1361.45","1361.45","1361.45","1 through 10","579.34","1873.9","other","Multiple Surgery"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1720.41","78.45","","1639.08","971.34","1639.08","1 through 10","579.34","1873.9","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","67.01","217.45","per diem",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","179.00","134.25","WELLPOINT [1015]","HB CH WELLPOINT","139.46","77.91","","137.04","137.04","137.04","1 through 10","67.01","217.45","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.43","78.45","","133.77","79.27","133.77","1 through 10","63.92","283.83","percent of total billed charges",""
"Remove Cerumen Impacted Unilate|BILATERAL PROCEDURE","PX-76001668","CDM","69210","CPT","0761","RC","","","50","outpatient","","","179.00","134.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","90.38","90.38","92.30","1 through 10","95.88","527.92","other","ASC "
"Remove Cerumen Impacted Unilate|BILATERAL PROCEDURE","PX-76001668","CDM","69210","CPT","0761","RC","","","50","outpatient","","","179.00","134.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","90.51","90.51","90.51","1 through 10","95.88","527.92","other","ASC "
"Remove Contraceptive Capsule","PX-76000102","CDM","11976","CPT","0761","RC","","","","both","","","1072.00","804.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","7497.47","7497.47","7497.47","1 through 10","459.89","835.2","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","AETNA [1001]","HB CH AETNA HMO / PPO","371.95","58.3","","1602.15","351.54","2343.98","1 through 10","165.93","497.07","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","429.76","214.88","2887.33","1 through 10","165.93","497.07","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","243.00","243.00","243.00","1 through 10","165.93","497.07","per diem",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","165.93","497.07","per diem",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","WELLPOINT [1015]","HB CH WELLPOINT","497.07","77.91","","488.31","488.31","488.31","1 through 10","165.93","497.07","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","137.00","134.16","274.00","17","165.93","567.68","other","ASC "
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","268.69","137.19","274.38","32","165.93","567.68","other","ASC "
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","378.33","59.3","","872.55","363.32","872.55","1 through 10","165.93","567.68","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","389.94","194.97","389.94","1 through 10","165.93","567.68","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","614.79","204.93","819.70","1 through 10","165.93","567.68","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","500.51","78.45","","3296.61","476.66","3296.61","1 through 10","165.93","567.68","percent of total billed charges",""
"Remove FB Muscle/Tendon Smp","PX-76000283","CDM","20520","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1080.16","50.1","","1137.25","1137.25","1137.25","1 through 10","862.4","1691.38","percent of total billed charges",""
"Remove FB Muscle/Tendon Smp","PX-76000283","CDM","20520","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1080.16","50.1","","2274.50","2274.50","2274.50","1 through 10","862.4","1691.38","percent of total billed charges",""
"Remove Renal Tube Fluoro","PX-76001227","CDM","50389","CPT","0761","RC","","","","both","","","1562.00","1171.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","784.31","784.31","784.31","1 through 10","562.25","1216.95","other","OPPS APC"
"Remove Suture Cerclage Under Anes","PX-72000038","CDM","59871","CPT","0361","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","2549.80","2549.80","2549.80","1 through 10","2361.27","3888.77","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","145.86","264.89","per diem",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","340.00","255.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2825.68","2825.68","2825.68","1 through 10","170","567.68","other","ASC "
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","6484.00","4863.00","MEDICARE [2001]","HB NWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12428.21","11654.50","12428.21","19","3436.52","12799.76","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","6484.00","4863.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12229.36","12229.36","12229.36","1 through 10","3436.52","12799.76","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","6484.00","4863.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12187.55","12179.65","12187.55","1 through 10","3436.52","12799.76","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","outpatient","","","6484.00","4863.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11297.59","","Case rate ($11,297.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","15997.39","15997.39","15997.39","1 through 10","2882.14","35192.65","other","ASC "
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","both","","","8995.00","6746.25","MEDICARE [2001]","HB NWH MEDICARE","22645.86","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22648.15","22648.15","22648.15","1 through 10","3858.86","23325.23","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Sgl Sys","PX-48000062","CDM","33227","CPT","0361","RC","","","","both","","","24720.00","18540.00","MEDICARE [2001]","HB NWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9828.22","9828.22","9828.22","1 through 10","4812.67","19259.35","other","OPPS APC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","both","","","8978.00","6733.50","MEDICARE [2001]","HB NWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2377.37","6994.76","other","OPPS APC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","outpatient","","","8978.00","6733.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5586.82","5372.86","5586.82","1 through 10","2377.37","7939.38","other","Multiple Surgery"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8343.05","","Case rate ($8,343.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,763.19. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7667.71","7667.71","7667.71","1 through 10","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","FALLON HEALTH [1008]","HB NWH MEDICARE","8343.05","","Case rate ($8,343.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,763.19. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7731.56","7731.56","7731.56","1 through 10","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","HUMANA [1012]","HB NWH MEDICARE","8343.05","","Case rate ($8,343.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,763.19. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6165.32","6165.32","6165.32","1 through 10","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","MEDICARE [2001]","HB NWH MEDICARE","8343.05","","Case rate ($8,343.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,763.19. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8483.82","8483.71","8499.07","58","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7436.11","","Case rate ($7,587.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,008.01. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7583.23","7582.83","7601.22","1 through 10","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","20702.96","15527.22","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7436.11","","Case rate ($7,587.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,794.80, add-ons for qualifying new technology services are included. If operating cost exceeds $52,937.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,521.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,008.01. The transfer operating threshold is the transfer adjustment factor * $7,794.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.86. The transfer capital threshold is the transfer adjustment factor * $579.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7610.34","7610.34","7610.34","1 through 10","7436.11","8990.09","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13216.21","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13446.21","13446.21","13485.78","1 through 10","12574.64","15202.47","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12831.27","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12951.59","12951.59","12951.59","1 through 10","12574.64","15202.47","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10430.02","10430.02","10430.02","1 through 10","12574.64","15202.47","case rate",""
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","12831.27","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22508.06","22508.06","22508.06","1 through 10","12574.64","15202.47","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","MEDICARE [2001]","HB NWH MEDICARE","12831.27","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14334.41","9790.76","14360.17","65","12574.64","15202.47","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12574.64","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12811.97","12811.97","14411.96","1 through 10","12574.64","15202.47","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","12574.64","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15796.61","15796.61","15796.61","1 through 10","12574.64","15202.47","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","31183.70","23387.77","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","12574.64","","Case rate ($12,831.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,181.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,323.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,922.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,850.72. The transfer operating threshold is the transfer adjustment factor * $13,181.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.55. The transfer capital threshold is the transfer adjustment factor * $980.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12805.97","12802.10","12845.48","1 through 10","12574.64","15202.47","other","Inpatient DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","15952.81","11964.61","MEDICARE [2001]","HB NWH MEDICARE","5718.57","","Case rate ($5,718.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,342.79, add-ons for qualifying new technology services are included. If operating cost exceeds $50,485.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,339.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,321.13. The transfer operating threshold is the transfer adjustment factor * $5,342.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $397.45. The transfer capital threshold is the transfer adjustment factor * $397.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5797.12","5797.12","5797.12","1 through 10","5096.93","6162.08","other","Inpatient DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","15952.81","11964.61","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","5096.93","","Case rate ($5,200.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,342.79, add-ons for qualifying new technology services are included. If operating cost exceeds $50,485.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,339.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,803.50. The transfer operating threshold is the transfer adjustment factor * $5,342.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $397.45. The transfer capital threshold is the transfer adjustment factor * $397.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5193.43","5193.43","5193.43","1 through 10","5096.93","6162.08","other","Inpatient DRG"
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","20775.66","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12432.6204","","Fee schedule rate ($21,535.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12432.6204","21535.28","21535.28","1 through 10","10211.01","35532.89","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","20775.66","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13054.1878","","Fee schedule rate ($22,611.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13054.1878","22611.92","22611.92","1 through 10","10211.01","35532.89","case rate",""
"Renal Failure,MODERATE","460","DRG","","","","","","","","inpatient","","","16551.82","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13054.1878","","Fee schedule rate ($15,731.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13054.1878","15731.92","15731.92","1 through 10","10211.01","35532.89","case rate",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","109.00","81.75","AETNA [1001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","22","8.51","103.55","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","109.00","81.75","TRICARE [160005]","HB NWH TRICARE","103.55","95","","116.46","10.46","116.46","1 through 10","8.51","103.55","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","109.00","81.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","25","8.96","85.51","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","81.49","42.17","81.49","12","8.96","85.51","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","100.93","100.93","100.93","1 through 10","21.55","173.85","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","183.00","137.25","TRICARE [160005]","HB NWH TRICARE","173.85","95","","26.50","26.50","26.50","1 through 10","21.55","173.85","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","104.31","104.31","133.96","1 through 10","22.69","143.56","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","136.85","136.85","178.00","1 through 10","22.69","143.56","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","464.71","67.87","1012.10","221","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1486.65","58.3","","293.04","293.04","293.04","11","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1351.50","53","","983.89","983.89","983.89","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1479.00","58","","677.18","677.18","677.18","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1593.75","62.5","","46.58","46.58","46.58","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","747.15","747.15","747.15","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","1141.67","481.21","1141.67","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","76.54","76.54","76.54","1 through 10","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","273.64","94.28","1367.51","138","1133.48","1986.71","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","720.78","230.14","2010.94","427","1275","2000.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1512.15","59.3","","344.45","344.45","344.45","1 through 10","1275","2000.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1275","2000.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","456.17","105.33","1284.66","242","1275","2000.48","percent of total billed charges",""
"Repair Primary Open/Prq Ruptured Achilles Tendon","PX-76000600","CDM","27650","CPT","0761","RC","","","","both","","","13401.00","10050.75","AETNA [1001]","HB CH AETNA HMO / PPO","7812.78","58.3","","9899.82","9899.82","9899.82","1 through 10","5749.03","10440.72","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","3849.59","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3846.25","3846.25","3846.25","1 through 10","2108.26","3849.59","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","MEDICARE [2001]","HB NWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11213.55","1877.00","11213.55","1 through 10","2108.26","3849.59","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","3754.00","3754.00","3754.00","1 through 10","2108.26","3849.59","per diem",""
"Repl Picc W/O Port/Pump","PX-76001102","CDM","36584","CPT","0761","RC","","","","both","","","2794.00","2095.50","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","1 through 10","1093.63","2176.81","other","OPPS APC"
"Repl Picc W/O Port/Pump","PX-76001102","CDM","36584","CPT","0761","RC","","","","both","","","2794.00","2095.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.90","1807.90","1807.90","1 through 10","1093.63","2176.81","other","OPPS APC"
"Repl Picc W/O Port/Pump","PX-76001102","CDM","36584","CPT","0761","RC","","","","outpatient","","","2794.00","2095.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1768.39","1768.39","1768.39","1 through 10","1093.63","4472.66","other","ASC "
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","AETNA [1001]","HB CH AETNA HMO / PPO","5142.06","58.3","","1530.90","1160.93","1884.08","89","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4674.60","53","","5253.92","5253.92","5253.92","1 through 10","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5115.60","58","","12181.47","12181.47","12181.47","1 through 10","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5512.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3920.49","44.45","","1910.74","891.94","1910.74","1 through 10","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","WELLPOINT [1015]","HB CH WELLPOINT","6871.66","77.91","","1829.79","1561.50","2617.12","88","3920.49","6871.66","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5230.26","59.3","","1359.46","1201.30","1689.00","61","4410","6919.29","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5230.26","59.3","","1718.92","1718.92","1718.92","1 through 10","4410","6919.29","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6919.29","78.45","","1910.74","1019.06","2344.84","74","4410","6919.29","percent of total billed charges",""
"Reposition Cv Cath W/Fluoro","PX-76001113","CDM","36597","CPT","0361","RC","","","","both","","","2856.00","2142.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1093.63","2225.11","per diem",""
"Rescj Lip > One-Fourth W/O Rcnstj","PX-75000002","CDM","40530","CPT","0761","RC","","","","both","","","6251.00","4688.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2681.68","4870.15","per diem",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1543.50","1157.62","AETNA [1001]","HB CH AETNA HMO / PPO","899.86","58.3","","2190.90","412.50","9264.59","16","686.09","1202.54","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1543.50","1157.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","895.23","58","","1903.20","1903.20","3826.66","1 through 10","686.09","1202.54","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1543.50","1157.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","964.69","62.5","","2186.25","2186.25","2186.25","32","686.09","1202.54","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1543.50","1157.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1126.76","73","","5556.60","5556.60","5556.60","1 through 10","686.09","1202.54","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1543.50","1157.62","WELLPOINT [1015]","HB CH WELLPOINT","1202.54","77.91","","1955.15","885.83","3150.40","26","686.09","1202.54","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1543.50","1157.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","915.30","59.3","","831.03","253.22","2394.88","18","771.75","1210.88","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1543.50","1157.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1210.88","78.45","","2481.69","1563.74","8149.28","1 through 10","771.75","1210.88","percent of total billed charges",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","22341.05","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12522.7457","","Fee schedule rate ($42,392.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12522.7457","13584.66","13584.66","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","22341.05","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","18564.59","","Case rate ($20,000.41). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $62,430.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20051.85","20051.85","20051.85","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","21394.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28114.18","","Fee schedule rate ($28,114.18). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,252.98) multiplied by length of stay and the outlier percent (100%).","28114.17","28114.17","28114.17","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","21394.46","","MASSHEALTH [3001]","HB NWH MEDICAID","11343.69","","Case rate ($12,221.04). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,651.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12252.46","2805.19","12252.46","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","21394.46","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","25506.39","","Fee schedule rate ($25,506.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25506.39","25506.39","25506.39","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","21394.46","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","11343.69","","Case rate ($12,221.04). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $54,651.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25949.49","25949.49","25949.49","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","16087.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17378.68","","Standard inlier is a Case rate ($17,378.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,466.97) for the length of stay and the standard reimbursement.","16588.96","16588.96","16588.96","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","16087.91","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18668.17","","Standard inlier is a Case rate ($18,668.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,649.87) for the length of stay and the standard reimbursement.","17819.61","17819.61","17819.61","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","16087.91","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12522.7457","","Fee schedule rate ($30,206.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12522.7457","6626.96","6626.96","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","28003.84","21002.88","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8709.67","","Case rate ($8,455.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,686.60, add-ons for qualifying new technology services are included. If operating cost exceeds $53,828.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,809.79. The transfer operating threshold is the transfer adjustment factor * $8,686.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.20. The transfer capital threshold is the transfer adjustment factor * $646.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8903.13","8903.13","11782.15","1 through 10","8286.87","9810.8769","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","28003.84","21002.88","HUMANA [1012]","HB NWH MEDICARE","9297.57","","Case rate ($9,297.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,686.60, add-ons for qualifying new technology services are included. If operating cost exceeds $53,828.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,651.38. The transfer operating threshold is the transfer adjustment factor * $8,686.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.20. The transfer capital threshold is the transfer adjustment factor * $646.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3044.10","3044.10","3044.10","1 through 10","8286.87","9810.8769","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","28003.84","21002.88","MEDICARE [2001]","HB NWH MEDICARE","9297.57","","Case rate ($9,297.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,686.60, add-ons for qualifying new technology services are included. If operating cost exceeds $53,828.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,651.38. The transfer operating threshold is the transfer adjustment factor * $8,686.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.20. The transfer capital threshold is the transfer adjustment factor * $646.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9468.78","5917.91","9485.80","44","8286.87","9810.8769","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","28003.84","21002.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8286.87","","Case rate ($8,455.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,686.60, add-ons for qualifying new technology services are included. If operating cost exceeds $53,828.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,809.79. The transfer operating threshold is the transfer adjustment factor * $8,686.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.20. The transfer capital threshold is the transfer adjustment factor * $646.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8456.60","7934.47","9786.94","1 through 10","8286.87","9810.8769","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","28003.84","21002.88","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8286.87","","Case rate ($8,455.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,686.60, add-ons for qualifying new technology services are included. If operating cost exceeds $53,828.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,588.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,809.79. The transfer operating threshold is the transfer adjustment factor * $8,686.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.20. The transfer capital threshold is the transfer adjustment factor * $646.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8480.30","8456.60","9863.95","1 through 10","8286.87","9810.8769","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13945.29","","Case rate ($13,539.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,504.47. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14479.70","12581.26","14515.29","1 through 10","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14886.60","","Case rate ($14,886.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,851.95. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13939.84","12122.07","13944.04","1 through 10","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","MEDICARE [2001]","HB NWH MEDICARE","14886.60","","Case rate ($14,886.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,851.95. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15428.16","6708.15","15455.90","159","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13268.34","","Case rate ($13,539.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,504.47. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13783.15","8986.61","13818.74","19","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","13268.34","","Case rate ($13,539.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,504.47. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15501.07","15501.07","15501.07","1 through 10","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13268.34","","Case rate ($13,539.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,504.47. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13783.13","12004.66","14162.59","12","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","34842.46","26131.84","WELLSENSE [1003]","HB NWH MEDICARE","14886.60","","Case rate ($14,886.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,908.35, add-ons for qualifying new technology services are included. If operating cost exceeds $59,050.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,976.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,851.95. The transfer operating threshold is the transfer adjustment factor * $13,908.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,034.65. The transfer capital threshold is the transfer adjustment factor * $1,034.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12015.68","12015.68","12015.68","1 through 10","13268.34","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations Without Cc/McC","179","MS-DRG","","","","","","","","inpatient","","","19717.02","14787.76","MEDICARE [2001]","HB NWH MEDICARE","6541.27","","Case rate ($6,541.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,719.66, add-ons for qualifying new technology services are included. If operating cost exceeds $51,861.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,041.39. The transfer operating threshold is the transfer adjustment factor * $6,719.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.88. The transfer capital threshold is the transfer adjustment factor * $499.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7346.15","7346.15","7359.35","1 through 10","6410.44","7611.5633","other","Inpatient Replacement Plans DRG"
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","36453.49","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14519.706","","Fee schedule rate ($56,493.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14519.706","56493.96","56493.96","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","36453.49","","MASSHEALTH [3001]","HB NWH MEDICAID","19388.24","","Case rate ($20,887.76). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $63,317.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20941.48","20941.48","20941.48","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","40410.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","28434.95","","Standard inlier is a Case rate ($28,434.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,818, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,036.45) for the length of stay and the standard reimbursement.","27147.28","27147.28","28434.94","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","40410.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30544.81","","Standard inlier is a Case rate ($30,544.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $40,818, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,335.71) for the length of stay and the standard reimbursement.","30544.80","30544.80","30544.80","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Malignancy,MODERATE","136","DRG","","","","","","","","inpatient","","","36437.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21485.91","","Standard inlier is a Case rate ($21,485.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $32,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,049.83) for the length of stay and the standard reimbursement.","20509.27","20509.27","20509.27","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Malignancy,MODERATE","136","DRG","","","","","","","","inpatient","","","36437.63","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","23884.01","","Fee schedule rate ($23,884.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23884.01","23884.01","23884.01","1 through 10","7521.34","93214.18","case rate",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","31189.51","23392.13","MEDICARE [2001]","HB NWH MEDICARE","9279.06","","Case rate ($9,279.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,532.12, add-ons for qualifying new technology services are included. If operating cost exceeds $54,674.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,651.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,569.97. The transfer operating threshold is the transfer adjustment factor * $9,532.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.10. The transfer capital threshold is the transfer adjustment factor * $709.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10615.94","10615.94","10615.94","1 through 10","9093.48","10993.82","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","31189.51","23392.13","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","9093.48","","Case rate ($9,279.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,532.12, add-ons for qualifying new technology services are included. If operating cost exceeds $54,674.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,651.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,569.97. The transfer operating threshold is the transfer adjustment factor * $9,532.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.10. The transfer capital threshold is the transfer adjustment factor * $709.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9479.32","9479.32","9479.32","1 through 10","9093.48","10993.82","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","31189.51","23392.13","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9093.48","","Case rate ($9,279.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,532.12, add-ons for qualifying new technology services are included. If operating cost exceeds $54,674.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,651.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,569.97. The transfer operating threshold is the transfer adjustment factor * $9,532.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.10. The transfer capital threshold is the transfer adjustment factor * $709.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9473.68","9473.68","9473.68","1 through 10","9093.48","10993.82","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","39122.14","29341.60","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","15759.50","","Case rate ($15,300.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,717.76, add-ons for qualifying new technology services are included. If operating cost exceeds $60,860.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,131.25. The transfer operating threshold is the transfer adjustment factor * $15,717.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.25. The transfer capital threshold is the transfer adjustment factor * $1,169.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15647.78","15647.78","15647.78","1 through 10","14994.48","17283.9942","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","39122.14","29341.60","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","12816.35","12816.35","12816.35","1 through 10","14994.48","17283.9942","case rate",""
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","39122.14","29341.60","MEDICARE [2001]","HB NWH MEDICARE","15300.49","","Case rate ($15,300.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,717.76, add-ons for qualifying new technology services are included. If operating cost exceeds $60,860.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,131.25. The transfer operating threshold is the transfer adjustment factor * $15,717.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.25. The transfer capital threshold is the transfer adjustment factor * $1,169.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16681.31","6951.10","16711.30","19","14994.48","17283.9942","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","39122.14","29341.60","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","14994.48","","Case rate ($15,300.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,717.76, add-ons for qualifying new technology services are included. If operating cost exceeds $60,860.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,111.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,131.25. The transfer operating threshold is the transfer adjustment factor * $15,717.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.25. The transfer capital threshold is the transfer adjustment factor * $1,169.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14898.13","14898.13","14898.13","1 through 10","14994.48","17283.9942","other","Inpatient DRG"
"Respiratory Neoplasms Without Cc/McC","182","MS-DRG","","","","","","","","inpatient","","","33841.22","25380.91","MEDICARE [2001]","HB NWH MEDICARE","7180.86","","Case rate ($7,180.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,708.97, add-ons for qualifying new technology services are included. If operating cost exceeds $51,851.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,441.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,681.77. The transfer operating threshold is the transfer adjustment factor * $6,708.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $499.08. The transfer capital threshold is the transfer adjustment factor * $499.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7993.23","7993.23","7993.23","1 through 10","6400.26","7737.76","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","17818.73","13364.05","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","7691.45","","Case rate ($7,691.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,186.02, add-ons for qualifying new technology services are included. If operating cost exceeds $52,328.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,476.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,156.89. The transfer operating threshold is the transfer adjustment factor * $7,186.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.57. The transfer capital threshold is the transfer adjustment factor * $534.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7053.98","7053.98","7053.98","1 through 10","6855.35","8019.979","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","17818.73","13364.05","MEDICARE [2001]","HB NWH MEDICARE","7691.45","","Case rate ($7,691.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,186.02, add-ons for qualifying new technology services are included. If operating cost exceeds $52,328.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,476.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,156.89. The transfer operating threshold is the transfer adjustment factor * $7,186.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.57. The transfer capital threshold is the transfer adjustment factor * $534.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7754.23","7740.32","7754.23","1 through 10","6855.35","8019.979","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","17818.73","13364.05","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6855.35","","Case rate ($6,995.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,186.02, add-ons for qualifying new technology services are included. If operating cost exceeds $52,328.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,476.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,460.68. The transfer operating threshold is the transfer adjustment factor * $7,186.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.57. The transfer capital threshold is the transfer adjustment factor * $534.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7704.38","7704.38","7704.38","1 through 10","6855.35","8019.979","other","Inpatient DRG"
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MINOR","144","DRG","","","","","","","","inpatient","","","10554.31","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11161.68","","Standard inlier is a Case rate ($11,161.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,097, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,584.44) for the length of stay and the standard reimbursement.","11133.29","11133.29","11133.29","1 through 10","3904.61","27284.87","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MINOR","144","DRG","","","","","","","","inpatient","","","10554.31","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8862.1561","","Fee schedule rate ($8,862.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8862.1561","5908.40","5908.40","1 through 10","3904.61","27284.87","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","144","DRG","","","","","","","","inpatient","","","14146.27","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15348.84","","Standard inlier is a Case rate ($15,348.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,178.83) for the length of stay and the standard reimbursement.","14653.09","14653.09","14653.09","1 through 10","3904.61","27284.87","case rate",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","61158.32","45868.74","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","23814.53","","Case rate ($23,814.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,463.99, add-ons for qualifying new technology services are included. If operating cost exceeds $69,606.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $21,994.65. The transfer operating threshold is the transfer adjustment factor * $24,463.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.88. The transfer capital threshold is the transfer adjustment factor * $1,819.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23150.63","23150.63","23150.63","1 through 10","23338.24","28215.41","other","Inpatient Replacement Plans DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","61158.32","45868.74","MEDICARE [2001]","HB NWH MEDICARE","23814.53","","Case rate ($23,814.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,463.99, add-ons for qualifying new technology services are included. If operating cost exceeds $69,606.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $21,994.65. The transfer operating threshold is the transfer adjustment factor * $24,463.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.88. The transfer capital threshold is the transfer adjustment factor * $1,819.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25614.65","25614.32","25660.70","1 through 10","23338.24","28215.41","other","Inpatient Replacement Plans DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","61158.32","45868.74","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","23338.24","","Case rate ($23,814.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,463.99, add-ons for qualifying new technology services are included. If operating cost exceeds $69,606.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $21,994.65. The transfer operating threshold is the transfer adjustment factor * $24,463.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.88. The transfer capital threshold is the transfer adjustment factor * $1,819.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22883.52","22883.52","22883.52","1 through 10","23338.24","28215.41","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","61158.32","45868.74","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","23338.24","","Case rate ($23,814.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,463.99, add-ons for qualifying new technology services are included. If operating cost exceeds $69,606.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $21,994.65. The transfer operating threshold is the transfer adjustment factor * $24,463.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.88. The transfer capital threshold is the transfer adjustment factor * $1,819.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25811.96","25811.96","25811.96","1 through 10","23338.24","28215.41","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","191497.28","143622.96","MEDICARE [2001]","HB NWH MEDICARE","55749.77","","Case rate ($55,749.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $57,270.15, add-ons for qualifying new technology services are included. If operating cost exceeds $102,412.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,202.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $51,489.43. The transfer operating threshold is the transfer adjustment factor * $57,270.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,260.34. The transfer capital threshold is the transfer adjustment factor * $4,260.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","66394.02","61724.07","73448.34","1 through 10","54634.77","63954.1408","other","Inpatient Replacement Plans DRG"
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"RESTRICTOR BONE 18.5MM UNIVERSAL SM CEMENT POLYMER","SUP-ITM-10016138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1530.90","1160.93","1884.08","89","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","5253.92","5253.92","5253.92","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","12181.47","12181.47","12181.47","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","1350.68","1350.68","1350.68","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1910.74","891.94","1910.74","1 through 10","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","1829.79","1561.50","2617.12","88","33.34","58.43","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1359.46","1201.30","1689.00","61","37.5","58.84","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","1718.92","1718.92","1718.92","1 through 10","37.5","58.84","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1910.74","1019.06","2344.84","74","37.5","58.84","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","1530.90","1160.93","1884.08","89","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","5253.92","5253.92","5253.92","1 through 10","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","147.90","58","","12181.47","12181.47","12181.47","1 through 10","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","159.38","62.5","","1350.68","1350.68","1350.68","1 through 10","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","1910.74","891.94","1910.74","1 through 10","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","1829.79","1561.50","2617.12","88","113.35","198.67","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","1359.46","1201.30","1689.00","61","127.5","200.05","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","151.22","59.3","","1718.92","1718.92","1718.92","1 through 10","127.5","200.05","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","1910.74","1019.06","2344.84","74","127.5","200.05","percent of total billed charges",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","39348.52","29511.39","MEDICARE [2001]","HB NWH MEDICARE","8785.23","","Case rate ($8,785.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,024.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,167.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,113.86. The transfer operating threshold is the transfer adjustment factor * $9,024.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.36. The transfer capital threshold is the transfer adjustment factor * $671.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9715.26","9715.26","9715.26","1 through 10","8609.53","10048.2129","other","Inpatient Replacement Plans DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","39348.52","29511.39","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8609.53","","Case rate ($8,785.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,024.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,167.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,613.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,113.86. The transfer operating threshold is the transfer adjustment factor * $9,024.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.36. The transfer capital threshold is the transfer adjustment factor * $671.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8684.77","8684.77","8684.77","1 through 10","8609.53","10048.2129","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","TRIS-DRG","","","","","","","","inpatient","","","53713.65","","TRICARE [160005]","HB NWH TRICARE","7145.10","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($10,017.86). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,839.30 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,565.48), capped at $9,033.24. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $53,839.30 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","8665.91","8665.91","8665.91","1 through 10","7145.1","7145.1","other","Inpatient DRGs"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","34386.64","25789.98","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","18978.35","","Case rate ($18,425.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,928.06, add-ons for qualifying new technology services are included. If operating cost exceeds $64,070.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,350.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,017.51. The transfer operating threshold is the transfer adjustment factor * $18,928.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.06. The transfer capital threshold is the transfer adjustment factor * $1,408.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18757.63","18757.63","18757.63","1 through 10","18057.07","20672.9545","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","34386.64","25789.98","MEDICARE [2001]","HB NWH MEDICARE","20259.38","","Case rate ($20,259.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,928.06, add-ons for qualifying new technology services are included. If operating cost exceeds $64,070.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,350.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,851.31. The transfer operating threshold is the transfer adjustment factor * $18,928.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.06. The transfer capital threshold is the transfer adjustment factor * $1,408.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19952.08","19952.08","19952.08","1 through 10","18057.07","20672.9545","other","Inpatient DRG"
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","48.90","46.54","48.90","1 through 10","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","91.65","91.65","91.65","1 through 10","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","149.64","58","","51.23","51.23","51.23","1 through 10","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","161.25","62.5","","65.12","36.89","65.12","1 through 10","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","46.29","46.29","46.29","1 through 10","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","64.65","45.40","120.92","18","114.68","201.01","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","276.77","63.10","312.43","11","129","202.4","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","both","","","1239.79","929.84","WELLPOINT [1015]","HB CH WELLPOINT","965.92","77.91","","352.06","352.06","352.06","1 through 10","551.09","965.92","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1239.79","929.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","972.62","78.45","","201.93","201.93","201.93","1 through 10","619.9","972.62","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","both","","","3593.75","2695.31","WELLPOINT [1015]","HB CH WELLPOINT","2799.89","77.91","","352.06","352.06","352.06","1 through 10","1597.42","2799.89","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","3593.75","2695.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2819.30","78.45","","201.93","201.93","201.93","1 through 10","1796.88","2819.3","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","both","","","6203.64","4652.73","WELLPOINT [1015]","HB CH WELLPOINT","4833.26","77.91","","352.06","352.06","352.06","1 through 10","2757.52","4833.26","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","6203.64","4652.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4866.76","78.45","","201.93","201.93","201.93","1 through 10","3101.82","4866.76","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","1780.00","1335.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","891.78","50.1","","248.00","248.00","248.00","1 through 10","763.62","1873.9","percent of total billed charges",""
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","both","","","5753.00","4314.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","4206.13","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4211.37","4211.37","4211.37","1 through 10","2468.04","4482.16","other","OPPS APC"
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","outpatient","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3293.22","","Case rate ($3,293.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4663.20","4663.20","4663.20","1 through 10","1873.9","4513.23","other","ASC "
"Revise Tips","PX-76001128","CDM","37183","CPT","0361","RC","","","","both","","","30661.00","22995.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","4210.68","","Case rate ($4,210.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","12379.40","12379.40","12379.40","1 through 10","4210.68","23887.99","other","Multiple Surgery"
"Revise/Rem Generator/Receiver Neuro","PX-76001496","CDM","63688","CPT","0761","RC","","","","outpatient","","","7470.00","5602.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5860.22","78.45","","8813.78","8813.78","8813.78","1 through 10","2988","5860.22","percent of total billed charges",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","72007.43","54005.57","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","31470.83","","Case rate ($30,554.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,387.47, add-ons for qualifying new technology services are included. If operating cost exceeds $76,529.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,276.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $28,219.28. The transfer operating threshold is the transfer adjustment factor * $31,387.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,334.92. The transfer capital threshold is the transfer adjustment factor * $2,334.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","30678.04","30678.04","30678.04","1 through 10","29943.12","36200.55","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","72007.43","54005.57","MEDICARE [2001]","HB NWH MEDICARE","30554.20","","Case rate ($30,554.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,387.47, add-ons for qualifying new technology services are included. If operating cost exceeds $76,529.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,276.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $28,219.28. The transfer operating threshold is the transfer adjustment factor * $31,387.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,334.92. The transfer capital threshold is the transfer adjustment factor * $2,334.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","32690.70","21794.88","32749.47","25","29943.12","36200.55","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","72007.43","54005.57","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","29943.12","","Case rate ($30,554.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,387.47, add-ons for qualifying new technology services are included. If operating cost exceeds $76,529.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,276.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $28,219.28. The transfer operating threshold is the transfer adjustment factor * $31,387.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,334.92. The transfer capital threshold is the transfer adjustment factor * $2,334.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","29196.16","29196.16","29205.01","1 through 10","29943.12","36200.55","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","72007.43","54005.57","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","29943.12","","Case rate ($30,554.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,387.47, add-ons for qualifying new technology services are included. If operating cost exceeds $76,529.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,276.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $28,219.28. The transfer operating threshold is the transfer adjustment factor * $31,387.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,334.92. The transfer capital threshold is the transfer adjustment factor * $2,334.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","29244.51","29244.51","54445.68","1 through 10","29943.12","36200.55","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","95906.49","71929.87","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","49587.70","","Case rate ($49,587.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,329.13, add-ons for qualifying new technology services are included. If operating cost exceeds $91,471.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,388.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $46,141.26. The transfer operating threshold is the transfer adjustment factor * $46,329.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,446.43. The transfer capital threshold is the transfer adjustment factor * $3,446.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","43313.65","43313.65","43313.65","1 through 10","44197.22","50380.4994","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","95906.49","71929.87","MEDICARE [2001]","HB NWH MEDICARE","49587.70","","Case rate ($49,587.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,329.13, add-ons for qualifying new technology services are included. If operating cost exceeds $91,471.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,388.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $46,141.26. The transfer operating threshold is the transfer adjustment factor * $46,329.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,446.43. The transfer capital threshold is the transfer adjustment factor * $3,446.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","48711.15","48711.15","48711.15","1 through 10","44197.22","50380.4994","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","95906.49","71929.87","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","44197.22","","Case rate ($45,099.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $46,329.13, add-ons for qualifying new technology services are included. If operating cost exceeds $91,471.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,388.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $41,652.77. The transfer operating threshold is the transfer adjustment factor * $46,329.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,446.43. The transfer capital threshold is the transfer adjustment factor * $3,446.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","43430.00","43430.00","43430.00","1 through 10","44197.22","50380.4994","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","24522.72","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","23488.75","23488.75","23488.75","1 through 10","23332.3","28208.22","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","23808.47","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","24680.90","24680.90","24680.90","1 through 10","23332.3","28208.22","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","ELDER SERVICES [1037]","HB NWH MEDICARE","23808.47","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22360.49","22360.49","22360.49","1 through 10","23332.3","28208.22","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","MEDICARE [2001]","HB NWH MEDICARE","23808.47","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25082.22","25037.21","25082.22","16","23332.3","28208.22","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","23332.30","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","22390.89","22390.89","22390.89","1 through 10","23332.3","28208.22","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","52626.58","39469.93","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","23332.30","","Case rate ($23,808.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $24,457.77, add-ons for qualifying new technology services are included. If operating cost exceeds $69,600.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,761.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $21,989.05. The transfer operating threshold is the transfer adjustment factor * $24,457.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,819.42. The transfer capital threshold is the transfer adjustment factor * $1,819.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","22377.09","22368.81","22401.11","1 through 10","23332.3","28208.22","other","Inpatient DRG"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1184.00","888.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1125.98","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1184.00","888.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","593.18","50.1","","2255.00","204.62","2255.00","1 through 10","526.29","928.85","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1184.00","888.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","928.85","78.45","","1733.64","1733.64","1733.64","1 through 10","526.29","928.85","percent of total billed charges",""
"Revision/Rmvl Peripheral/Gastric Npgr","PX-76001566","CDM","64595","CPT","0761","RC","","","","outpatient","","","7470.00","5602.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3742.47","50.1","","4663.20","2331.60","4663.20","1 through 10","2988","5860.22","percent of total billed charges",""
"Revision/Rmvl Peripheral/Gastric Npgr","PX-98301717","CDM","64595","CPT","0983","RC","","","","outpatient","","","1160.00","870.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","581.16","50.1","","4663.20","2331.60","4663.20","1 through 10","464","910.02","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","36.29","36.29","36.29","63","5.56","62.7","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","48.18","73","","46.72","46.72","46.72","1 through 10","5.56","62.7","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","TRICARE [160005]","HB NWH TRICARE","62.70","95","","6.83","6.83","6.83","1 through 10","5.56","62.7","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.34","44.45","","49.20","49.20","49.20","1 through 10","5.56","62.7","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","37.50","37.50","37.82","60","5.85","51.78","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","39.14","59.3","","37.50","37.50","37.50","1 through 10","5.85","51.78","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","49.20","29.16","49.20","63","5.85","51.78","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","21.09","15.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.01","52.2","","10.86","10.86","10.86","30","10.55","11.01","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","141.00","105.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.61","59.3","","93.56","80.28","93.56","1 through 10","19.95","122.01","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1530.90","1160.93","1884.08","89","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","5253.92","5253.92","5253.92","1 through 10","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.96","58","","12181.47","12181.47","12181.47","1 through 10","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","101.25","62.5","","1350.68","1350.68","1350.68","1 through 10","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","1910.74","891.94","1910.74","1 through 10","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","1829.79","1561.50","2617.12","88","72.01","126.21","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1359.46","1201.30","1689.00","61","81","127.09","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","96.07","59.3","","1718.92","1718.92","1718.92","1 through 10","81","127.09","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","1910.74","1019.06","2344.84","74","81","127.09","percent of total billed charges",""
"Rmvl & Rplcmt Xtrnl Accessible Nephrourtrl Cath","PX-76002202","CDM","50387","CPT","0761","RC","","","","outpatient","","","4346.00","3259.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3867.48","3726.56","3867.48","1 through 10","1565.78","3409.44","other","Multiple Surgery"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","outpatient","","","9000.00","6750.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25154.21","","Case rate ($25,154.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","36372.99","36372.99","36372.99","1 through 10","4500","47095.48","other","ASC "
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","9351.00","7013.25","MEDICARE [2001]","HB NWH MEDICARE","26653.50","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26656.20","26656.20","26656.20","1 through 10","4956.03","27453.11","other","OPPS APC"
"Rmvl Spinal Nstim Eltrd Plate/Paddle Incl Fluor","PX-76001492","CDM","63662","CPT","0761","RC","","","","outpatient","","","6064.00","4548.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4757.21","78.45","","8813.78","8813.78","8813.78","1 through 10","2425.6","4757.21","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","464.71","67.87","1012.10","221","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","293.04","293.04","293.04","11","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","983.89","983.89","983.89","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","522.00","58","","677.18","677.18","677.18","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","562.50","62.5","","46.58","46.58","46.58","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","747.15","747.15","747.15","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","1141.67","481.21","1141.67","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","76.54","76.54","76.54","1 through 10","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","273.64","94.28","1367.51","138","400.05","701.19","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","720.78","230.14","2010.94","427","450","706.05","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","533.70","59.3","","344.45","344.45","344.45","1 through 10","450","706.05","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1120.13","1120.13","1120.13","1 through 10","450","706.05","percent of total billed charges",""
"ROD 5.4 L180MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP PK/1EA","SUP-ITM-10258409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","456.17","105.33","1284.66","242","450","706.05","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","2190.90","412.50","9264.59","16","200.03","350.6","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","1903.20","1903.20","3826.66","1 through 10","200.03","350.6","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","2186.25","2186.25","2186.25","32","200.03","350.6","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","5556.60","5556.60","5556.60","1 through 10","200.03","350.6","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","1955.15","885.83","3150.40","26","200.03","350.6","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","831.03","253.22","2394.88","18","225","353.03","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","2481.69","1563.74","8149.28","1 through 10","225","353.03","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","AETNA [1001]","HB CH AETNA HMO / PPO","283.76","58.3","","2190.90","412.50","9264.59","16","216.35","379.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.30","58","","1903.20","1903.20","3826.66","1 through 10","216.35","379.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.20","62.5","","2186.25","2186.25","2186.25","32","216.35","379.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.31","73","","5556.60","5556.60","5556.60","1 through 10","216.35","379.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","WELLPOINT [1015]","HB CH WELLPOINT","379.20","77.91","","1955.15","885.83","3150.40","26","216.35","379.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.62","59.3","","831.03","253.22","2394.88","18","243.36","381.83","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.83","78.45","","2481.69","1563.74","8149.28","1 through 10","243.36","381.83","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","AETNA [1001]","HB CH AETNA HMO / PPO","311.18","58.3","","2190.90","412.50","9264.59","16","237.26","415.85","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","309.58","58","","1903.20","1903.20","3826.66","1 through 10","237.26","415.85","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","333.60","62.5","","2186.25","2186.25","2186.25","32","237.26","415.85","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","389.64","73","","5556.60","5556.60","5556.60","1 through 10","237.26","415.85","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","WELLPOINT [1015]","HB CH WELLPOINT","415.85","77.91","","1955.15","885.83","3150.40","26","237.26","415.85","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","533.76","400.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.52","59.3","","831.03","253.22","2394.88","18","266.88","418.73","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","533.76","400.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.73","78.45","","2481.69","1563.74","8149.28","1 through 10","266.88","418.73","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","AETNA [1001]","HB CH AETNA HMO / PPO","1689.53","58.3","","1530.90","1160.93","1884.08","89","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1535.94","53","","5253.92","5253.92","5253.92","1 through 10","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1680.84","58","","12181.47","12181.47","12181.47","1 through 10","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1811.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1288.16","44.45","","1910.74","891.94","1910.74","1 through 10","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","WELLPOINT [1015]","HB CH WELLPOINT","2257.83","77.91","","1829.79","1561.50","2617.12","88","1288.16","2257.83","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1359.46","1201.30","1689.00","61","1449","2273.48","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1718.92","1718.92","1718.92","1 through 10","1449","2273.48","percent of total billed charges",""
"ROD FLUTED 18X75MM KNEE MOD II I/B EA","SUP-ITM-10001798","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2273.48","78.45","","1910.74","1019.06","2344.84","74","1449","2273.48","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","464.71","67.87","1012.10","221","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","293.04","293.04","293.04","11","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","983.89","983.89","983.89","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","677.18","677.18","677.18","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","46.58","46.58","46.58","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","747.15","747.15","747.15","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","1141.67","481.21","1141.67","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","76.54","76.54","76.54","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","273.64","94.28","1367.51","138","320.04","560.95","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","720.78","230.14","2010.94","427","360","564.84","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","426.96","59.3","","344.45","344.45","344.45","1 through 10","360","564.84","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1120.13","1120.13","1120.13","1 through 10","360","564.84","percent of total billed charges",""
"ROD PERCUTANEOUS 5.4X130MM STRAIGHT","SUP-ITM-10154502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","456.17","105.33","1284.66","242","360","564.84","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","464.71","67.87","1012.10","221","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","293.04","293.04","293.04","11","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","983.89","983.89","983.89","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","677.18","677.18","677.18","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","46.58","46.58","46.58","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","747.15","747.15","747.15","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","1141.67","481.21","1141.67","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","76.54","76.54","76.54","1 through 10","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","273.64","94.28","1367.51","138","320.04","560.95","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","720.78","230.14","2010.94","427","360","564.84","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","426.96","59.3","","344.45","344.45","344.45","1 through 10","360","564.84","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1120.13","1120.13","1120.13","1 through 10","360","564.84","percent of total billed charges",""
"ROD SPINE 5.5X30MM CD HORIZON SOLERA CAPPED COBALT CHROME","SUP-ITM-10212612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","456.17","105.33","1284.66","242","360","564.84","percent of total billed charges",""
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","outpatient","","","3050.00","2287.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1808.65","59.3","","1696.55","1696.55","1696.55","1 through 10","807.41","2392.73","percent of total billed charges",""
"Rp Loclzj Tum Spect 2 Area/Sep Acquisj Img","PX-34000187","CDM","78831","CPT","0341","RC","","","","both","","","5287.00","3965.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1596.68","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1595.30","1595.30","1595.30","1 through 10","1472.82","4622.47","other","OPPS APC"
"Rp Loclzj Tum Spect 2 Area/Sep Acquisj Img","PX-34000187","CDM","78831","CPT","0341","RC","","","","both","","","5287.00","3965.25","MEDICARE [2001]","HB NWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","1 through 10","1472.82","4622.47","other","OPPS APC"
"Rp Loclzj Tum Spect 2 Area/Sep Acquisj Img","PX-34000187","CDM","78831","CPT","0341","RC","","","","both","","","5287.00","3965.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1519.33","1519.33","1519.33","1 through 10","1472.82","4622.47","other","OPPS APC"
"Rp Loclzj Tum Spect 2 Area/Sep Acquisj Img","PX-34000187","CDM","78831","CPT","0341","RC","","","","outpatient","","","5287.00","3965.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3135.19","59.3","","3012.63","3012.63","3012.63","1 through 10","2350.07","4147.65","percent of total billed charges",""
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","both","","","1566.00","1174.50","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","761.55","1220.07","other","OPPS APC"
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","outpatient","","","1566.00","1174.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","629.65","1233.17","1 through 10","696.09","1228.53","other","ASC "
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","outpatient","","","1566.00","1174.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1228.53","78.45","","693.88","693.88","693.88","1 through 10","696.09","1228.53","percent of total billed charges",""
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1473.00","1104.75","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","13","654.75","1147.61","other","OPPS APC"
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1473.00","1104.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1091.15","1099.05","1 through 10","654.75","1147.61","other","OPPS APC"
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","outpatient","","","1473.00","1104.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1233.17","1259.29","1 through 10","736.5","1155.57","other","ASC "
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","outpatient","","","1473.00","1104.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","1789.64","1789.64","1 through 10","736.5","1155.57","other","Multiple Surgery"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","1145.70","1145.70","1 through 10","696.09","1220.07","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","696.09","1220.07","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","1972.41","1972.41","1 through 10","696.09","1220.07","other","Multiple Surgery"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","MEDICARE [2001]","HB NWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","1 through 10","696.09","1220.07","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","969.58","969.58","969.58","1 through 10","696.09","1220.07","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1566.00","1174.50","WELLPOINT [1015]","HB CH WELLPOINT","1220.07","77.91","","1199.51","1199.51","1199.51","1 through 10","696.09","1220.07","percent of total billed charges",""
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","outpatient","","","1566.00","1174.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1257.55","1257.55","1257.55","1 through 10","761.55","1228.53","other","ASC "
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","outpatient","","","1566.00","1174.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1233.17","1259.29","1 through 10","761.55","1228.53","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","AETNA [1001]","HB CH AETNA HMO / PPO","1308.84","58.3","","5990.92","4687.96","5990.92","1 through 10","963.11","17460.7","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6817.79","6817.79","6817.79","1 through 10","963.11","17460.7","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","MEDICARE [2001]","HB NWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","15","963.11","17460.7","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7271.44","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6791.08","6791.08","6791.08","1 through 10","963.11","17460.7","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6789.39","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6803.94","6803.94","6803.94","1 through 10","963.11","17460.7","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","WELLPOINT [1015]","HB CH WELLPOINT","1749.08","77.91","","10131.69","10131.69","10131.69","1 through 10","963.11","17460.7","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8361.31","8187.60","8361.31","1 through 10","1122.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","8372.89","8199.18","8372.89","28","1122.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1761.20","78.45","","6356.44","6356.44","6356.44","1 through 10","1122.5","12722.53","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","AETNA [1001]","HB CH AETNA HMO / PPO","943.29","58.3","","7293.89","3339.63","9899.82","1 through 10","694.12","11865.47","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","ELDER SERVICES [1037]","HB NWH MEDICARE","4488.08","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4107.15","4107.15","4107.15","1 through 10","694.12","11865.47","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","MEDICARE [2001]","HB NWH MEDICARE","4488.08","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","7069.32","1 through 10","694.12","11865.47","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","5681.95","2781.96","5681.95","1 through 10","809","7939.38","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","5689.82","2844.91","5689.82","18","809","7939.38","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1269.32","78.45","","6356.44","4396.54","7418.92","1 through 10","809","7939.38","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","AETNA [1001]","HB CH AETNA HMO / PPO","2049.25","58.3","","6142.31","6142.31","6142.31","1 through 10","1507.94","17460.7","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","MEDICARE [2001]","HB NWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","1507.94","17460.7","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8361.31","8361.31","8361.31","1 through 10","1757.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","8372.89","8199.18","8372.89","1 through 10","1757.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7776.68","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41388.14","41388.14","41388.14","1 through 10","1160.02","11865.47","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","5681.95","5563.91","5681.95","1 through 10","1352","7939.38","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","5689.82","5689.82","5689.82","1 through 10","1352","7939.38","other","ASC "
"Rpr Aa Hernia Recr < 3 Cm Reducible","PX-36000518","CDM","49613","CPT","0361","RC","","","","outpatient","","","2447.00","1835.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1225.95","50.1","","5689.82","5689.82","5689.82","1 through 10","978.8","1919.67","percent of total billed charges",""
"Rpr Aa Hernia Recr < 3 Cm Reducible","PX-98302395","CDM","49613","CPT","0983","RC","","","","outpatient","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","911.82","50.1","","5689.82","5689.82","5689.82","1 through 10","728","1427.79","percent of total billed charges",""
"Rpr Aa Hernia Recr 3-10 Cm Reducible","PX-98302397","CDM","49615","CPT","0983","RC","","","","both","","","2752.00","2064.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1720.00","62.5","","3218.00","3218.00","3218.00","1 through 10","1180.61","2144.08","percent of total billed charges",""
"Rpr Aa Hernia Recr 3-10 Cm Reducible","PX-98302397","CDM","49615","CPT","0983","RC","","","","outpatient","","","2752.00","2064.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1378.75","50.1","","5689.82","5689.82","5689.82","1 through 10","1100.8","2158.94","percent of total billed charges",""
"Rpr Ectropion Extensive|BILATERAL PROCEDURE","PX-76001642","CDM","67917","CPT","0761","RC","","","50","both","","","4874.00","3655.50","MEDICARE [2001]","HB NWH MEDICARE","2966.94","","APC Price ($2,966.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2770.53","2770.53","2770.53","1 through 10","2907.6","9519.28","other","OPPS APC"
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","567.40","567.40","567.40","1 through 10","482.89","1079.47","other","Multiple Surgery"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","904.00","678.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","254.29","259.68","1 through 10","314.08","970.06","other","ASC "
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","both","","","1044.00","783.00","MEDICARE [2001]","HB NWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","314.08","813.38","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","847.00","635.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","259.68","259.68","1 through 10","314.08","664.47","other","ASC "
"Rpr Lac Intermd Hnd/Ft/Gen 12.6-20.","PX-76000130","CDM","12045","CPT","0761","RC","","","","outpatient","","","1167.00","875.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","692.03","59.3","","6462.41","6462.41","6462.41","1 through 10","482.89","970.06","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","800.00","600.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","369.05","369.05","369.05","1 through 10","314.08","970.06","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","259.68","259.68","1 through 10","314.08","970.06","other","ASC "
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","4554.69","4554.69","4554.69","1 through 10","314.08","970.06","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","839.00","629.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","522.24","522.24","522.24","1 through 10","176.45","653.66","per diem",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","839.00","629.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","285.32","285.32","285.32","1 through 10","176.45","1873.9","other","ASC "
"Rpr Lac Smp Face/Ear/Lip 2.6-5.0cm","PX-76000113","CDM","12013","CPT","0761","RC","","","","outpatient","","","568.00","426.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","285.72","285.72","285.72","1 through 10","176.45","1873.9","other","ASC "
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","480.00","360.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","284.64","59.3","","273.66","273.66","273.66","1 through 10","176.45","567.68","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","534.00","400.50","WELLPOINT [1015]","HB CH WELLPOINT","416.04","77.91","","408.76","408.76","408.76","1 through 10","176.45","416.04","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","534.00","400.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.66","59.3","","275.04","275.04","275.04","1 through 10","176.45","567.68","percent of total billed charges",""
"Rpr Tendon Digit Flex N-Zone 2","PX-76000488","CDM","26350","CPT","0761","RC","","","","both","","","7493.00","5619.75","AETNA [1001]","HB CH AETNA HMO / PPO","4368.42","58.3","","2492.72","2492.72","2492.72","1 through 10","3214.5","5837.8","percent of total billed charges",""
"Rpr Tendon Finger Extensor W/O","PX-76000491","CDM","26418","CPT","0761","RC","","","","both","","","2942.00","2206.50","AETNA [1001]","HB CH AETNA HMO / PPO","1715.19","58.3","","2492.72","2492.72","2492.72","1 through 10","1182.01","2292.11","percent of total billed charges",""
"Rpr Tendon Forearm Exten Primary","PX-76000444","CDM","25270","CPT","0761","RC","","","","both","","","8660.00","6495.00","TRICARE [160005]","HB NWH TRICARE","3660.51","","APC Price ($3,853.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","7581.00","7581.00","7581.00","1 through 10","2361.01","6747.01","other","Tricare OPPS"
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","214","14.1","112.1","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","86.14","73","","65.21","65.21","65.21","1 through 10","14.1","112.1","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.45","44.45","","88.41","52.39","88.41","1 through 10","14.1","112.1","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.45","44.45","","88.41","88.41","88.41","1 through 10","14.1","112.1","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","67.39","186","14.84","92.57","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","88.41","151","14.84","92.57","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","61","12.62","143.45","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","151.00","113.25","TRICARE [160005]","HB NWH TRICARE","143.45","95","","14.74","14.74","14.74","1 through 10","12.62","143.45","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.12","44.45","","66.97","66.97","113.01","1 through 10","12.62","143.45","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","57","13.29","118.46","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","1 through 10","13.29","118.46","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","66.97","113.01","33","13.29","118.46","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","71.00","53.25","TRICARE [160005]","HB NWH TRICARE","67.45","95","","69.00","69.00","69.00","1 through 10","9.39","67.45","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","71.00","53.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","40.43","12","6.19","55.7","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","31.44","53.05","12","6.19","55.7","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","both","","","146.00","109.50","AETNA [1001]","HB CH AETNA HMO / PPO","85.12","58.3","","216.59","216.59","216.59","1 through 10","15.75","138.7","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1533.00","1149.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1445.32","1389.52","1445.32","1 through 10","558.04","1194.36","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1533.00","1149.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","516.38","516.38","516.38","1 through 10","558.04","1194.36","per diem",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1533.00","1149.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","558.04","1194.36","per diem",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","460.75","460.75","921.49","1 through 10","558.04","1202.64","other","ASC "
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","461.38","451.81","922.76","1 through 10","558.04","1202.64","other","ASC "
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","909.07","59.3","","873.73","873.73","873.73","1 through 10","558.04","1202.64","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","820.32","820.32","820.32","1 through 10","558.04","1202.64","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.42","44.45","","679.30","679.30","679.30","1 through 10","558.04","1202.64","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1533.00","1149.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1202.64","78.45","","1146.28","1146.28","1146.28","1 through 10","558.04","1202.64","percent of total billed charges",""
"Schizophrenia And Other Severe Psychotic Disorders,MAJOR","750","DRG","","","","","","","","inpatient","","","49790.81","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","36575.13","","Case rate ($39,403.93). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $81,833.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7636.72","7636.72","7636.72","1 through 10","886.93","61650.53","case rate",""
"Schizophrenia And Other Severe Psychotic Disorders,MAJOR","750","DRG","","","","","","","","inpatient","","","49790.81","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","36575.13","","Case rate ($39,403.93). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $81,833.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","616.61","616.61","616.61","1 through 10","886.93","61650.53","case rate",""
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","both","","","633.00","474.75","MEDICARE [2001]","HB NWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1769.51","1924.13","1 through 10","335.49","1981.66","other","OPPS APC"
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","outpatient","","","633.00","474.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","938.11","1 through 10","281.37","1873.9","other","ASC "
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","107","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","135.78","73","","132.13","132.13","132.13","1 through 10","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.78","73","","102.63","69.26","153.85","1 through 10","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB NWH TRICARE","176.70","95","","27.88","26.49","28.69","32","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","176.70","95","","27.88","27.88","27.88","1 through 10","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","139.15","82.46","139.15","35","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","82.46","82.46","139.15","1 through 10","27.32","209.31","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","53.68","2704","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","34.83","1 through 10","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","34.83","6485","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","106.07","1116","69.66","145.92","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","110.30","59.3","","433.64","433.64","433.64","1 through 10","69.66","145.92","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","82.46","139.15","1057","69.66","145.92","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","AETNA [1001]","HB CH AETNA HMO / PPO","260.25","58.3","","464.71","67.87","1012.10","221","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.25","58.3","","293.04","293.04","293.04","11","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.59","53","","983.89","983.89","983.89","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","258.91","58","","677.18","677.18","677.18","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","279.00","62.5","","46.58","46.58","46.58","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","747.15","747.15","747.15","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","1141.67","481.21","1141.67","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","76.54","76.54","76.54","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","WELLPOINT [1015]","HB CH WELLPOINT","347.79","77.91","","273.64","94.28","1367.51","138","198.42","347.79","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.72","59.3","","720.78","230.14","2010.94","427","223.2","350.2","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","264.72","59.3","","344.45","344.45","344.45","1 through 10","223.2","350.2","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","1120.13","1120.13","1120.13","1 through 10","223.2","350.2","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","456.17","105.33","1284.66","242","223.2","350.2","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","AETNA [1001]","HB CH AETNA HMO / PPO","117.13","58.3","","464.71","67.87","1012.10","221","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.13","58.3","","293.04","293.04","293.04","11","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.48","53","","983.89","983.89","983.89","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","116.53","58","","677.18","677.18","677.18","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","125.57","62.5","","46.58","46.58","46.58","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","146.66","73","","747.15","747.15","747.15","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.30","44.45","","1141.67","481.21","1141.67","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.30","44.45","","76.54","76.54","76.54","1 through 10","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","WELLPOINT [1015]","HB CH WELLPOINT","156.53","77.91","","273.64","94.28","1367.51","138","89.3","156.53","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.14","59.3","","720.78","230.14","2010.94","427","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","119.14","59.3","","344.45","344.45","344.45","1 through 10","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","157.61","78.45","","1120.13","1120.13","1120.13","1 through 10","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","157.61","78.45","","456.17","105.33","1284.66","242","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","AETNA [1001]","HB CH AETNA HMO / PPO","128.78","58.3","","464.71","67.87","1012.10","221","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","128.78","58.3","","293.04","293.04","293.04","11","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.07","53","","983.89","983.89","983.89","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","128.12","58","","677.18","677.18","677.18","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","138.06","62.5","","46.58","46.58","46.58","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","161.25","73","","747.15","747.15","747.15","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.19","44.45","","1141.67","481.21","1141.67","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.19","44.45","","76.54","76.54","76.54","1 through 10","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","WELLPOINT [1015]","HB CH WELLPOINT","172.10","77.91","","273.64","94.28","1367.51","138","98.19","172.1","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","130.99","59.3","","720.78","230.14","2010.94","427","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","130.99","59.3","","344.45","344.45","344.45","1 through 10","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","173.29","78.45","","1120.13","1120.13","1120.13","1 through 10","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.3X8MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10002189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.29","78.45","","456.17","105.33","1284.66","242","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","AETNA [1001]","HB CH AETNA HMO / PPO","138.49","58.3","","464.71","67.87","1012.10","221","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.49","58.3","","293.04","293.04","293.04","11","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.90","53","","983.89","983.89","983.89","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.77","58","","677.18","677.18","677.18","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.46","62.5","","46.58","46.58","46.58","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.40","73","","747.15","747.15","747.15","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.59","44.45","","1141.67","481.21","1141.67","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.59","44.45","","76.54","76.54","76.54","1 through 10","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","WELLPOINT [1015]","HB CH WELLPOINT","185.07","77.91","","273.64","94.28","1367.51","138","105.59","185.07","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.86","59.3","","720.78","230.14","2010.94","427","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.86","59.3","","344.45","344.45","344.45","1 through 10","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.35","78.45","","1120.13","1120.13","1120.13","1 through 10","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.3X8MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.35","78.45","","456.17","105.33","1284.66","242","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","AETNA [1001]","HB CH AETNA HMO / PPO","77.01","58.3","","464.71","67.87","1012.10","221","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","77.01","58.3","","293.04","293.04","293.04","11","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","70.01","53","","983.89","983.89","983.89","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","76.61","58","","677.18","677.18","677.18","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","82.56","62.5","","46.58","46.58","46.58","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","96.43","73","","747.15","747.15","747.15","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.71","44.45","","1141.67","481.21","1141.67","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.71","44.45","","76.54","76.54","76.54","1 through 10","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","WELLPOINT [1015]","HB CH WELLPOINT","102.91","77.91","","273.64","94.28","1367.51","138","58.71","102.91","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.33","59.3","","720.78","230.14","2010.94","427","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","78.33","59.3","","344.45","344.45","344.45","1 through 10","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","103.62","78.45","","1120.13","1120.13","1120.13","1 through 10","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","103.62","78.45","","456.17","105.33","1284.66","242","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","AETNA [1001]","HB CH AETNA HMO / PPO","67.30","58.3","","464.71","67.87","1012.10","221","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","67.30","58.3","","293.04","293.04","293.04","11","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.18","53","","983.89","983.89","983.89","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.96","58","","677.18","677.18","677.18","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","72.15","62.5","","46.58","46.58","46.58","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","84.27","73","","747.15","747.15","747.15","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.31","44.45","","1141.67","481.21","1141.67","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.31","44.45","","76.54","76.54","76.54","1 through 10","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","WELLPOINT [1015]","HB CH WELLPOINT","89.94","77.91","","273.64","94.28","1367.51","138","51.31","89.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.46","59.3","","720.78","230.14","2010.94","427","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","68.46","59.3","","344.45","344.45","344.45","1 through 10","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","90.56","78.45","","1120.13","1120.13","1120.13","1 through 10","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.56","78.45","","456.17","105.33","1284.66","242","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","AETNA [1001]","HB CH AETNA HMO / PPO","73.77","58.3","","464.71","67.87","1012.10","221","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","73.77","58.3","","293.04","293.04","293.04","11","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","67.07","53","","983.89","983.89","983.89","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","73.39","58","","677.18","677.18","677.18","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","79.09","62.5","","46.58","46.58","46.58","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","92.37","73","","747.15","747.15","747.15","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.25","44.45","","1141.67","481.21","1141.67","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.25","44.45","","76.54","76.54","76.54","1 through 10","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.54","94.90","WELLPOINT [1015]","HB CH WELLPOINT","98.59","77.91","","273.64","94.28","1367.51","138","56.25","98.59","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.54","94.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","75.04","59.3","","720.78","230.14","2010.94","427","63.27","99.27","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.54","94.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","75.04","59.3","","344.45","344.45","344.45","1 through 10","63.27","99.27","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.54","94.90","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","99.27","78.45","","1120.13","1120.13","1120.13","1 through 10","63.27","99.27","percent of total billed charges",""
"SCREW BONE 1.5X16MM CORTEX TI SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.54","94.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","99.27","78.45","","456.17","105.33","1284.66","242","63.27","99.27","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","AETNA [1001]","HB CH AETNA HMO / PPO","290.47","58.3","","464.71","67.87","1012.10","221","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","290.47","58.3","","293.04","293.04","293.04","11","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","264.07","53","","983.89","983.89","983.89","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","288.98","58","","677.18","677.18","677.18","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","311.40","62.5","","46.58","46.58","46.58","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","363.72","73","","747.15","747.15","747.15","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.47","44.45","","1141.67","481.21","1141.67","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.47","44.45","","76.54","76.54","76.54","1 through 10","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.24","373.68","WELLPOINT [1015]","HB CH WELLPOINT","388.18","77.91","","273.64","94.28","1367.51","138","221.47","388.18","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.24","373.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","295.46","59.3","","720.78","230.14","2010.94","427","249.12","390.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.24","373.68","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","295.46","59.3","","344.45","344.45","344.45","1 through 10","249.12","390.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.24","373.68","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","390.87","78.45","","1120.13","1120.13","1120.13","1 through 10","249.12","390.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM COMPRESSION SS SELF DRILLING SHORT THREAD HEADLESS","SUP-ITM-10079286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.24","373.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","390.87","78.45","","456.17","105.33","1284.66","242","249.12","390.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","AETNA [1001]","HB CH AETNA HMO / PPO","165.67","58.3","","464.71","67.87","1012.10","221","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","165.67","58.3","","293.04","293.04","293.04","11","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","150.60","53","","983.89","983.89","983.89","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","164.81","58","","677.18","677.18","677.18","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","177.60","62.5","","46.58","46.58","46.58","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","207.44","73","","747.15","747.15","747.15","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.31","44.45","","1141.67","481.21","1141.67","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.31","44.45","","76.54","76.54","76.54","1 through 10","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","WELLPOINT [1015]","HB CH WELLPOINT","221.39","77.91","","273.64","94.28","1367.51","138","126.31","221.39","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","168.51","59.3","","720.78","230.14","2010.94","427","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","168.51","59.3","","344.45","344.45","344.45","1 through 10","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","222.92","78.45","","1120.13","1120.13","1120.13","1 through 10","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X18MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","222.92","78.45","","456.17","105.33","1284.66","242","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","AETNA [1001]","HB CH AETNA HMO / PPO","59.54","58.3","","464.71","67.87","1012.10","221","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","59.54","58.3","","293.04","293.04","293.04","11","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.12","53","","983.89","983.89","983.89","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","59.23","58","","677.18","677.18","677.18","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","63.83","62.5","","46.58","46.58","46.58","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","74.55","73","","747.15","747.15","747.15","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.39","44.45","","1141.67","481.21","1141.67","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.39","44.45","","76.54","76.54","76.54","1 through 10","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","WELLPOINT [1015]","HB CH WELLPOINT","79.56","77.91","","273.64","94.28","1367.51","138","45.39","79.56","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.56","59.3","","720.78","230.14","2010.94","427","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","60.56","59.3","","344.45","344.45","344.45","1 through 10","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","80.11","78.45","","1120.13","1120.13","1120.13","1 through 10","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.5X8MM HAND CORTICAL SELF TAPPING MODULAR SYSTEM TI","SUP-ITM-10002259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.11","78.45","","456.17","105.33","1284.66","242","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","AETNA [1001]","HB CH AETNA HMO / PPO","163.99","58.3","","464.71","67.87","1012.10","221","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.99","58.3","","293.04","293.04","293.04","11","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","149.08","53","","983.89","983.89","983.89","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","163.14","58","","677.18","677.18","677.18","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","175.80","62.5","","46.58","46.58","46.58","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","205.33","73","","747.15","747.15","747.15","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","125.03","44.45","","1141.67","481.21","1141.67","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","125.03","44.45","","76.54","76.54","76.54","1 through 10","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.28","210.96","WELLPOINT [1015]","HB CH WELLPOINT","219.15","77.91","","273.64","94.28","1367.51","138","125.03","219.15","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.80","59.3","","720.78","230.14","2010.94","427","140.64","220.66","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","166.80","59.3","","344.45","344.45","344.45","1 through 10","140.64","220.66","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","220.66","78.45","","1120.13","1120.13","1120.13","1 through 10","140.64","220.66","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.28","210.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.66","78.45","","456.17","105.33","1284.66","242","140.64","220.66","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","AETNA [1001]","HB CH AETNA HMO / PPO","1496.11","58.3","","464.71","67.87","1012.10","221","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1496.11","58.3","","293.04","293.04","293.04","11","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1360.10","53","","983.89","983.89","983.89","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1488.41","58","","677.18","677.18","677.18","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1603.89","62.5","","46.58","46.58","46.58","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","747.15","747.15","747.15","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","1141.67","481.21","1141.67","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","76.54","76.54","76.54","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","WELLPOINT [1015]","HB CH WELLPOINT","1999.35","77.91","","273.64","94.28","1367.51","138","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1521.77","59.3","","720.78","230.14","2010.94","427","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1521.77","59.3","","344.45","344.45","344.45","1 through 10","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","1120.13","1120.13","1120.13","1 through 10","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","456.17","105.33","1284.66","242","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","464.71","67.87","1012.10","221","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","293.04","293.04","293.04","11","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","983.89","983.89","983.89","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","840.16","58","","677.18","677.18","677.18","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","905.34","62.5","","46.58","46.58","46.58","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","747.15","747.15","747.15","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","1141.67","481.21","1141.67","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","76.54","76.54","76.54","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","273.64","94.28","1367.51","138","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","720.78","230.14","2010.94","427","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","858.99","59.3","","344.45","344.45","344.45","1 through 10","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","1120.13","1120.13","1120.13","1 through 10","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","456.17","105.33","1284.66","242","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","AETNA [1001]","HB CH AETNA HMO / PPO","1496.11","58.3","","464.71","67.87","1012.10","221","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1496.11","58.3","","293.04","293.04","293.04","11","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1360.10","53","","983.89","983.89","983.89","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1488.41","58","","677.18","677.18","677.18","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1603.89","62.5","","46.58","46.58","46.58","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","747.15","747.15","747.15","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","1141.67","481.21","1141.67","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","76.54","76.54","76.54","1 through 10","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","WELLPOINT [1015]","HB CH WELLPOINT","1999.35","77.91","","273.64","94.28","1367.51","138","1140.69","1999.35","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1521.77","59.3","","720.78","230.14","2010.94","427","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1521.77","59.3","","344.45","344.45","344.45","1 through 10","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","1120.13","1120.13","1120.13","1 through 10","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","456.17","105.33","1284.66","242","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","464.71","67.87","1012.10","221","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.39","58.3","","293.04","293.04","293.04","11","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","983.89","983.89","983.89","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.44","58","","677.18","677.18","677.18","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.75","62.5","","46.58","46.58","46.58","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","747.15","747.15","747.15","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","1141.67","481.21","1141.67","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","76.54","76.54","76.54","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","273.64","94.28","1367.51","138","141.35","247.75","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","720.78","230.14","2010.94","427","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.57","59.3","","344.45","344.45","344.45","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","1120.13","1120.13","1120.13","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","456.17","105.33","1284.66","242","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","AETNA [1001]","HB CH AETNA HMO / PPO","346.30","58.3","","464.71","67.87","1012.10","221","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.30","58.3","","293.04","293.04","293.04","11","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","314.82","53","","983.89","983.89","983.89","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","344.52","58","","677.18","677.18","677.18","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","371.25","62.5","","46.58","46.58","46.58","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","433.62","73","","747.15","747.15","747.15","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.03","44.45","","1141.67","481.21","1141.67","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.03","44.45","","76.54","76.54","76.54","1 through 10","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","WELLPOINT [1015]","HB CH WELLPOINT","462.79","77.91","","273.64","94.28","1367.51","138","264.03","462.79","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.24","59.3","","720.78","230.14","2010.94","427","297","465.99","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","352.24","59.3","","344.45","344.45","344.45","1 through 10","297","465.99","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","465.99","78.45","","1120.13","1120.13","1120.13","1 through 10","297","465.99","percent of total billed charges",""
"SCREW BONE 10X2.4MM ORTHOLOC FIXATION TI LOCKING GOLD HEAD BRONZE","SUP-ITM-10077275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.99","78.45","","456.17","105.33","1284.66","242","297","465.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","464.71","67.87","1012.10","221","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","293.04","293.04","293.04","11","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","983.89","983.89","983.89","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","200.10","58","","677.18","677.18","677.18","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","215.63","62.5","","46.58","46.58","46.58","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","747.15","747.15","747.15","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","1141.67","481.21","1141.67","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","76.54","76.54","76.54","1 through 10","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","273.64","94.28","1367.51","138","153.35","268.79","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","720.78","230.14","2010.94","427","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","204.59","59.3","","344.45","344.45","344.45","1 through 10","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","1120.13","1120.13","1120.13","1 through 10","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","456.17","105.33","1284.66","242","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","464.71","67.87","1012.10","221","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","293.04","293.04","293.04","11","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","983.89","983.89","983.89","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.63","58","","677.18","677.18","677.18","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.31","62.5","","46.58","46.58","46.58","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","747.15","747.15","747.15","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","1141.67","481.21","1141.67","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","76.54","76.54","76.54","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","273.64","94.28","1367.51","138","105.48","184.88","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","720.78","230.14","2010.94","427","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.72","59.3","","344.45","344.45","344.45","1 through 10","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","1120.13","1120.13","1120.13","1 through 10","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","456.17","105.33","1284.66","242","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","464.71","67.87","1012.10","221","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","293.04","293.04","293.04","11","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","983.89","983.89","983.89","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","180.96","58","","677.18","677.18","677.18","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","195.00","62.5","","46.58","46.58","46.58","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","747.15","747.15","747.15","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","1141.67","481.21","1141.67","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","76.54","76.54","76.54","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","273.64","94.28","1367.51","138","138.68","243.08","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","720.78","230.14","2010.94","427","156","244.76","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","185.02","59.3","","344.45","344.45","344.45","1 through 10","156","244.76","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","1120.13","1120.13","1120.13","1 through 10","156","244.76","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","456.17","105.33","1284.66","242","156","244.76","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","464.71","67.87","1012.10","221","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","388.28","58.3","","293.04","293.04","293.04","11","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","352.98","53","","983.89","983.89","983.89","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","386.28","58","","677.18","677.18","677.18","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","416.25","62.5","","46.58","46.58","46.58","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","486.18","73","","747.15","747.15","747.15","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.04","44.45","","1141.67","481.21","1141.67","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.04","44.45","","76.54","76.54","76.54","1 through 10","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","WELLPOINT [1015]","HB CH WELLPOINT","518.88","77.91","","273.64","94.28","1367.51","138","296.04","518.88","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","394.94","59.3","","720.78","230.14","2010.94","427","333","522.48","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","394.94","59.3","","344.45","344.45","344.45","1 through 10","333","522.48","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","1120.13","1120.13","1120.13","1 through 10","333","522.48","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","456.17","105.33","1284.66","242","333","522.48","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","464.71","67.87","1012.10","221","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","293.04","293.04","293.04","11","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","983.89","983.89","983.89","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","548.10","58","","677.18","677.18","677.18","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","590.63","62.5","","46.58","46.58","46.58","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","747.15","747.15","747.15","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","1141.67","481.21","1141.67","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","76.54","76.54","76.54","1 through 10","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","273.64","94.28","1367.51","138","420.05","736.25","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","720.78","230.14","2010.94","427","472.5","741.35","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","560.39","59.3","","344.45","344.45","344.45","1 through 10","472.5","741.35","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","1120.13","1120.13","1120.13","1 through 10","472.5","741.35","percent of total billed charges",""
"SCREW BONE 10X7MM INTERFERENCE PEEK OPTIMA BIOABSORBABLE BIO TENODESIS","SUP-ITM-10077608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","456.17","105.33","1284.66","242","472.5","741.35","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","464.71","67.87","1012.10","221","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.39","58.3","","293.04","293.04","293.04","11","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","983.89","983.89","983.89","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.44","58","","677.18","677.18","677.18","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.75","62.5","","46.58","46.58","46.58","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","747.15","747.15","747.15","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","1141.67","481.21","1141.67","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","76.54","76.54","76.54","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","273.64","94.28","1367.51","138","141.35","247.75","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","720.78","230.14","2010.94","427","159","249.47","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.57","59.3","","344.45","344.45","344.45","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","1120.13","1120.13","1120.13","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","456.17","105.33","1284.66","242","159","249.47","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","464.71","67.87","1012.10","221","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","293.04","293.04","293.04","11","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","983.89","983.89","983.89","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","739.50","58","","677.18","677.18","677.18","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","796.88","62.5","","46.58","46.58","46.58","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","747.15","747.15","747.15","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","1141.67","481.21","1141.67","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","76.54","76.54","76.54","1 through 10","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","273.64","94.28","1367.51","138","566.74","993.35","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","720.78","230.14","2010.94","427","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","756.08","59.3","","344.45","344.45","344.45","1 through 10","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","1120.13","1120.13","1120.13","1 through 10","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","456.17","105.33","1284.66","242","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","464.71","67.87","1012.10","221","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","293.04","293.04","293.04","11","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","983.89","983.89","983.89","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","180.96","58","","677.18","677.18","677.18","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","195.00","62.5","","46.58","46.58","46.58","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","747.15","747.15","747.15","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","1141.67","481.21","1141.67","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","76.54","76.54","76.54","1 through 10","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","273.64","94.28","1367.51","138","138.68","243.08","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","720.78","230.14","2010.94","427","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","185.02","59.3","","344.45","344.45","344.45","1 through 10","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","1120.13","1120.13","1120.13","1 through 10","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","456.17","105.33","1284.66","242","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB CH AETNA HMO / PPO","124.18","58.3","","464.71","67.87","1012.10","221","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","124.18","58.3","","293.04","293.04","293.04","11","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","112.89","53","","983.89","983.89","983.89","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","123.54","58","","677.18","677.18","677.18","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","133.13","62.5","","46.58","46.58","46.58","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","155.49","73","","747.15","747.15","747.15","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.68","44.45","","1141.67","481.21","1141.67","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.68","44.45","","76.54","76.54","76.54","1 through 10","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","WELLPOINT [1015]","HB CH WELLPOINT","165.95","77.91","","273.64","94.28","1367.51","138","94.68","165.95","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.31","59.3","","720.78","230.14","2010.94","427","106.5","167.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","126.31","59.3","","344.45","344.45","344.45","1 through 10","106.5","167.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","1120.13","1120.13","1120.13","1 through 10","106.5","167.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","456.17","105.33","1284.66","242","106.5","167.1","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 13X3.5MM SPINE CERVICAL ZEVO SELF DRILLING ANTERIOR","SUP-ITM-10165321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","464.71","67.87","1012.10","221","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","293.04","293.04","293.04","11","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","983.89","983.89","983.89","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","182.70","58","","677.18","677.18","677.18","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","196.88","62.5","","46.58","46.58","46.58","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","747.15","747.15","747.15","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","1141.67","481.21","1141.67","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","76.54","76.54","76.54","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","273.64","94.28","1367.51","138","140.02","245.42","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","720.78","230.14","2010.94","427","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","186.80","59.3","","344.45","344.45","344.45","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","1120.13","1120.13","1120.13","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","456.17","105.33","1284.66","242","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","464.71","67.87","1012.10","221","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.69","58.3","","293.04","293.04","293.04","11","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","96.99","53","","983.89","983.89","983.89","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","106.14","58","","677.18","677.18","677.18","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","114.38","62.5","","46.58","46.58","46.58","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","747.15","747.15","747.15","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.34","44.45","","1141.67","481.21","1141.67","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.34","44.45","","76.54","76.54","76.54","1 through 10","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","WELLPOINT [1015]","HB CH WELLPOINT","142.58","77.91","","273.64","94.28","1367.51","138","81.34","142.58","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","720.78","230.14","2010.94","427","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","108.52","59.3","","344.45","344.45","344.45","1 through 10","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","1120.13","1120.13","1120.13","1 through 10","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","456.17","105.33","1284.66","242","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","464.71","67.87","1012.10","221","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","293.04","293.04","293.04","11","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","983.89","983.89","983.89","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","147.90","58","","677.18","677.18","677.18","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","159.38","62.5","","46.58","46.58","46.58","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","747.15","747.15","747.15","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","1141.67","481.21","1141.67","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","76.54","76.54","76.54","1 through 10","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","273.64","94.28","1367.51","138","113.35","198.67","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","720.78","230.14","2010.94","427","127.5","200.05","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","151.22","59.3","","344.45","344.45","344.45","1 through 10","127.5","200.05","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","1120.13","1120.13","1120.13","1 through 10","127.5","200.05","percent of total billed charges",""
"SCREW BONE 14X3.5MM FOOT ANKLE CORTICAL TITANIUM LOCKING LOW PROFILE T 15 HEXALOBE DRIVE","SUP-ITM-10029811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","456.17","105.33","1284.66","242","127.5","200.05","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","464.71","67.87","1012.10","221","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","293.04","293.04","293.04","11","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","983.89","983.89","983.89","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","60.90","58","","677.18","677.18","677.18","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.63","62.5","","46.58","46.58","46.58","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","747.15","747.15","747.15","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","1141.67","481.21","1141.67","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","76.54","76.54","76.54","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","273.64","94.28","1367.51","138","46.67","81.81","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","720.78","230.14","2010.94","427","52.5","82.37","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.27","59.3","","344.45","344.45","344.45","1 through 10","52.5","82.37","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","1120.13","1120.13","1120.13","1 through 10","52.5","82.37","percent of total billed charges",""
"SCREW BONE 14X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","456.17","105.33","1284.66","242","52.5","82.37","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","2190.90","412.50","9264.59","16","146.69","257.1","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","191.40","58","","1903.20","1903.20","3826.66","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","206.25","62.5","","2186.25","2186.25","2186.25","32","146.69","257.1","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","5556.60","5556.60","5556.60","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","1955.15","885.83","3150.40","26","146.69","257.1","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","831.03","253.22","2394.88","18","165","258.89","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","2481.69","1563.74","8149.28","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","AETNA [1001]","HB CH AETNA HMO / PPO","95.48","58.3","","464.71","67.87","1012.10","221","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","95.48","58.3","","293.04","293.04","293.04","11","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","86.80","53","","983.89","983.89","983.89","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","94.99","58","","677.18","677.18","677.18","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","102.36","62.5","","46.58","46.58","46.58","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","747.15","747.15","747.15","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","1141.67","481.21","1141.67","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","76.54","76.54","76.54","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","WELLPOINT [1015]","HB CH WELLPOINT","127.59","77.91","","273.64","94.28","1367.51","138","72.8","127.59","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.12","59.3","","720.78","230.14","2010.94","427","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","97.12","59.3","","344.45","344.45","344.45","1 through 10","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","1120.13","1120.13","1120.13","1 through 10","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","456.17","105.33","1284.66","242","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","AETNA [1001]","HB CH AETNA HMO / PPO","603.41","58.3","","464.71","67.87","1012.10","221","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","603.41","58.3","","293.04","293.04","293.04","11","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","548.55","53","","983.89","983.89","983.89","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","600.30","58","","677.18","677.18","677.18","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","646.88","62.5","","46.58","46.58","46.58","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","755.55","73","","747.15","747.15","747.15","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","460.06","44.45","","1141.67","481.21","1141.67","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","460.06","44.45","","76.54","76.54","76.54","1 through 10","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","WELLPOINT [1015]","HB CH WELLPOINT","806.37","77.91","","273.64","94.28","1367.51","138","460.06","806.37","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","613.76","59.3","","720.78","230.14","2010.94","427","517.5","811.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","613.76","59.3","","344.45","344.45","344.45","1 through 10","517.5","811.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","811.96","78.45","","1120.13","1120.13","1120.13","1 through 10","517.5","811.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","811.96","78.45","","456.17","105.33","1284.66","242","517.5","811.96","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","464.71","67.87","1012.10","221","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","293.04","293.04","293.04","11","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","983.89","983.89","983.89","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.63","58","","677.18","677.18","677.18","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.31","62.5","","46.58","46.58","46.58","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","747.15","747.15","747.15","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","1141.67","481.21","1141.67","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","76.54","76.54","76.54","1 through 10","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","273.64","94.28","1367.51","138","105.48","184.88","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","720.78","230.14","2010.94","427","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.72","59.3","","344.45","344.45","344.45","1 through 10","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","1120.13","1120.13","1120.13","1 through 10","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","456.17","105.33","1284.66","242","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","464.71","67.87","1012.10","221","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","150.41","58.3","","293.04","293.04","293.04","11","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","983.89","983.89","983.89","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","149.64","58","","677.18","677.18","677.18","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","161.25","62.5","","46.58","46.58","46.58","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","747.15","747.15","747.15","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.68","44.45","","1141.67","481.21","1141.67","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.68","44.45","","76.54","76.54","76.54","1 through 10","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","273.64","94.28","1367.51","138","114.68","201.01","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","720.78","230.14","2010.94","427","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","152.99","59.3","","344.45","344.45","344.45","1 through 10","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","1120.13","1120.13","1120.13","1 through 10","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","456.17","105.33","1284.66","242","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","464.71","67.87","1012.10","221","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","332.31","58.3","","293.04","293.04","293.04","11","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","983.89","983.89","983.89","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","330.60","58","","677.18","677.18","677.18","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","356.25","62.5","","46.58","46.58","46.58","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","747.15","747.15","747.15","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","1141.67","481.21","1141.67","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","76.54","76.54","76.54","1 through 10","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","273.64","94.28","1367.51","138","253.37","444.09","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","720.78","230.14","2010.94","427","285","447.17","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","338.01","59.3","","344.45","344.45","344.45","1 through 10","285","447.17","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","1120.13","1120.13","1120.13","1 through 10","285","447.17","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","456.17","105.33","1284.66","242","285","447.17","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","464.71","67.87","1012.10","221","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","157.41","58.3","","293.04","293.04","293.04","11","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","983.89","983.89","983.89","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","156.60","58","","677.18","677.18","677.18","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","46.58","46.58","46.58","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","747.15","747.15","747.15","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","1141.67","481.21","1141.67","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","76.54","76.54","76.54","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","273.64","94.28","1367.51","138","120.02","210.36","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","720.78","230.14","2010.94","427","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","160.11","59.3","","344.45","344.45","344.45","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","1120.13","1120.13","1120.13","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","456.17","105.33","1284.66","242","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","AETNA [1001]","HB CH AETNA HMO / PPO","227.37","58.3","","464.71","67.87","1012.10","221","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.37","58.3","","293.04","293.04","293.04","11","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.70","53","","983.89","983.89","983.89","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","226.20","58","","677.18","677.18","677.18","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","243.75","62.5","","46.58","46.58","46.58","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","747.15","747.15","747.15","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.36","44.45","","1141.67","481.21","1141.67","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.36","44.45","","76.54","76.54","76.54","1 through 10","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","WELLPOINT [1015]","HB CH WELLPOINT","303.85","77.91","","273.64","94.28","1367.51","138","173.36","303.85","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.27","59.3","","720.78","230.14","2010.94","427","195","305.96","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","231.27","59.3","","344.45","344.45","344.45","1 through 10","195","305.96","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","1120.13","1120.13","1120.13","1 through 10","195","305.96","percent of total billed charges",""
"SCREW BONE 16X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","456.17","105.33","1284.66","242","195","305.96","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","464.71","67.87","1012.10","221","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.63","58.3","","293.04","293.04","293.04","11","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.75","53","","983.89","983.89","983.89","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","217.50","58","","677.18","677.18","677.18","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","234.38","62.5","","46.58","46.58","46.58","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","747.15","747.15","747.15","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","1141.67","481.21","1141.67","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","76.54","76.54","76.54","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","WELLPOINT [1015]","HB CH WELLPOINT","292.16","77.91","","273.64","94.28","1367.51","138","166.69","292.16","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","720.78","230.14","2010.94","427","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","222.38","59.3","","344.45","344.45","344.45","1 through 10","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","1120.13","1120.13","1120.13","1 through 10","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","456.17","105.33","1284.66","242","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB CH AETNA HMO / PPO","325.31","58.3","","464.71","67.87","1012.10","221","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","325.31","58.3","","293.04","293.04","293.04","11","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","295.74","53","","983.89","983.89","983.89","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","323.64","58","","677.18","677.18","677.18","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","348.75","62.5","","46.58","46.58","46.58","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","407.34","73","","747.15","747.15","747.15","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.03","44.45","","1141.67","481.21","1141.67","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.03","44.45","","76.54","76.54","76.54","1 through 10","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","WELLPOINT [1015]","HB CH WELLPOINT","434.74","77.91","","273.64","94.28","1367.51","138","248.03","434.74","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","330.89","59.3","","720.78","230.14","2010.94","427","279","437.75","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","330.89","59.3","","344.45","344.45","344.45","1 through 10","279","437.75","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","437.75","78.45","","1120.13","1120.13","1120.13","1 through 10","279","437.75","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","437.75","78.45","","456.17","105.33","1284.66","242","279","437.75","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","AETNA [1001]","HB CH AETNA HMO / PPO","93.83","58.3","","464.71","67.87","1012.10","221","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","93.83","58.3","","293.04","293.04","293.04","11","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.30","53","","983.89","983.89","983.89","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.35","58","","677.18","677.18","677.18","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","100.59","62.5","","46.58","46.58","46.58","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","117.49","73","","747.15","747.15","747.15","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.54","44.45","","1141.67","481.21","1141.67","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.54","44.45","","76.54","76.54","76.54","1 through 10","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","WELLPOINT [1015]","HB CH WELLPOINT","125.40","77.91","","273.64","94.28","1367.51","138","71.54","125.4","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.44","59.3","","720.78","230.14","2010.94","427","80.48","126.27","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","95.44","59.3","","344.45","344.45","344.45","1 through 10","80.48","126.27","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","126.27","78.45","","1120.13","1120.13","1120.13","1 through 10","80.48","126.27","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.27","78.45","","456.17","105.33","1284.66","242","80.48","126.27","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","AETNA [1001]","HB CH AETNA HMO / PPO","103.54","58.3","","464.71","67.87","1012.10","221","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","103.54","58.3","","293.04","293.04","293.04","11","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.13","53","","983.89","983.89","983.89","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","103.01","58","","677.18","677.18","677.18","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","111.00","62.5","","46.58","46.58","46.58","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","129.65","73","","747.15","747.15","747.15","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.94","44.45","","1141.67","481.21","1141.67","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.94","44.45","","76.54","76.54","76.54","1 through 10","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.60","133.20","WELLPOINT [1015]","HB CH WELLPOINT","138.37","77.91","","273.64","94.28","1367.51","138","78.94","138.37","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.60","133.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.32","59.3","","720.78","230.14","2010.94","427","88.8","139.33","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.60","133.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","105.32","59.3","","344.45","344.45","344.45","1 through 10","88.8","139.33","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.60","133.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","139.33","78.45","","1120.13","1120.13","1120.13","1 through 10","88.8","139.33","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.60","133.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.33","78.45","","456.17","105.33","1284.66","242","88.8","139.33","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","AETNA [1001]","HB CH AETNA HMO / PPO","265.85","58.3","","464.71","67.87","1012.10","221","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","265.85","58.3","","293.04","293.04","293.04","11","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.68","53","","983.89","983.89","983.89","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","264.48","58","","677.18","677.18","677.18","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","285.00","62.5","","46.58","46.58","46.58","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","332.88","73","","747.15","747.15","747.15","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.69","44.45","","1141.67","481.21","1141.67","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.69","44.45","","76.54","76.54","76.54","1 through 10","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB CH WELLPOINT","355.27","77.91","","273.64","94.28","1367.51","138","202.69","355.27","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","270.41","59.3","","720.78","230.14","2010.94","427","228","357.73","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","270.41","59.3","","344.45","344.45","344.45","1 through 10","228","357.73","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","357.73","78.45","","1120.13","1120.13","1120.13","1 through 10","228","357.73","percent of total billed charges",""
"SCREW BONE 2.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED AQUA","SUP-ITM-10057126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.73","78.45","","456.17","105.33","1284.66","242","228","357.73","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","AETNA [1001]","HB CH AETNA HMO / PPO","586.30","58.3","","464.71","67.87","1012.10","221","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","586.30","58.3","","293.04","293.04","293.04","11","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","533.00","53","","983.89","983.89","983.89","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","583.28","58","","677.18","677.18","677.18","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","628.54","62.5","","46.58","46.58","46.58","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","734.13","73","","747.15","747.15","747.15","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.02","44.45","","1141.67","481.21","1141.67","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.02","44.45","","76.54","76.54","76.54","1 through 10","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","WELLPOINT [1015]","HB CH WELLPOINT","783.51","77.91","","273.64","94.28","1367.51","138","447.02","783.51","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","596.36","59.3","","720.78","230.14","2010.94","427","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","596.36","59.3","","344.45","344.45","344.45","1 through 10","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","788.94","78.45","","1120.13","1120.13","1120.13","1 through 10","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.0X14MM COMPRESSION SS LOW PROFILE","SUP-ITM-10028134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.94","78.45","","456.17","105.33","1284.66","242","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","1530.90","1160.93","1884.08","89","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","5253.92","5253.92","5253.92","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.44","58","","12181.47","12181.47","12181.47","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.75","62.5","","1350.68","1350.68","1350.68","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","1910.74","891.94","1910.74","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","1829.79","1561.50","2617.12","88","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","1359.46","1201.30","1689.00","61","159","249.47","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.57","59.3","","1718.92","1718.92","1718.92","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 2.0X23MM APTUS TITANIUM CORTEX HEXADRIVE 6","SUP-ITM-10051648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","1910.74","1019.06","2344.84","74","159","249.47","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","AETNA [1001]","HB CH AETNA HMO / PPO","128.39","58.3","","464.71","67.87","1012.10","221","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","128.39","58.3","","293.04","293.04","293.04","11","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","116.72","53","","983.89","983.89","983.89","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","127.73","58","","677.18","677.18","677.18","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","137.64","62.5","","46.58","46.58","46.58","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","160.77","73","","747.15","747.15","747.15","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.89","44.45","","1141.67","481.21","1141.67","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.89","44.45","","76.54","76.54","76.54","1 through 10","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.23","165.17","WELLPOINT [1015]","HB CH WELLPOINT","171.58","77.91","","273.64","94.28","1367.51","138","97.89","171.58","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.23","165.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","130.60","59.3","","720.78","230.14","2010.94","427","110.12","172.77","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.23","165.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","130.60","59.3","","344.45","344.45","344.45","1 through 10","110.12","172.77","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.23","165.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","172.77","78.45","","1120.13","1120.13","1120.13","1 through 10","110.12","172.77","percent of total billed charges",""
"SCREW BONE 2.3X9MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10152610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.23","165.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","172.77","78.45","","456.17","105.33","1284.66","242","110.12","172.77","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","AETNA [1001]","HB CH AETNA HMO / PPO","78.30","58.3","","464.71","67.87","1012.10","221","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.30","58.3","","293.04","293.04","293.04","11","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.18","53","","983.89","983.89","983.89","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","77.90","58","","677.18","677.18","677.18","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","83.94","62.5","","46.58","46.58","46.58","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","747.15","747.15","747.15","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","1141.67","481.21","1141.67","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","76.54","76.54","76.54","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","WELLPOINT [1015]","HB CH WELLPOINT","104.64","77.91","","273.64","94.28","1367.51","138","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","79.65","59.3","","720.78","230.14","2010.94","427","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","79.65","59.3","","344.45","344.45","344.45","1 through 10","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","1120.13","1120.13","1120.13","1 through 10","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","456.17","105.33","1284.66","242","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","AETNA [1001]","HB CH AETNA HMO / PPO","190.26","58.3","","464.71","67.87","1012.10","221","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","190.26","58.3","","293.04","293.04","293.04","11","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","172.96","53","","983.89","983.89","983.89","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","189.28","58","","677.18","677.18","677.18","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","203.96","62.5","","46.58","46.58","46.58","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","747.15","747.15","747.15","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","1141.67","481.21","1141.67","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","76.54","76.54","76.54","1 through 10","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","WELLPOINT [1015]","HB CH WELLPOINT","254.25","77.91","","273.64","94.28","1367.51","138","145.06","254.25","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.52","59.3","","720.78","230.14","2010.94","427","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","193.52","59.3","","344.45","344.45","344.45","1 through 10","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","1120.13","1120.13","1120.13","1 through 10","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","456.17","105.33","1284.66","242","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","AETNA [1001]","HB CH AETNA HMO / PPO","100.16","58.3","","464.71","67.87","1012.10","221","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.16","58.3","","293.04","293.04","293.04","11","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.05","53","","983.89","983.89","983.89","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","99.64","58","","677.18","677.18","677.18","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","107.38","62.5","","46.58","46.58","46.58","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","125.41","73","","747.15","747.15","747.15","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.37","44.45","","1141.67","481.21","1141.67","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.37","44.45","","76.54","76.54","76.54","1 through 10","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.80","128.85","WELLPOINT [1015]","HB CH WELLPOINT","133.85","77.91","","273.64","94.28","1367.51","138","76.37","133.85","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.80","128.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.88","59.3","","720.78","230.14","2010.94","427","85.9","134.78","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.80","128.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","101.88","59.3","","344.45","344.45","344.45","1 through 10","85.9","134.78","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.80","128.85","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","134.78","78.45","","1120.13","1120.13","1120.13","1 through 10","85.9","134.78","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.80","128.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.78","78.45","","456.17","105.33","1284.66","242","85.9","134.78","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","AETNA [1001]","HB CH AETNA HMO / PPO","146.92","58.3","","464.71","67.87","1012.10","221","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","146.92","58.3","","293.04","293.04","293.04","11","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","133.56","53","","983.89","983.89","983.89","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","146.16","58","","677.18","677.18","677.18","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","157.50","62.5","","46.58","46.58","46.58","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","183.96","73","","747.15","747.15","747.15","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.01","44.45","","1141.67","481.21","1141.67","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.01","44.45","","76.54","76.54","76.54","1 through 10","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB CH WELLPOINT","196.33","77.91","","273.64","94.28","1367.51","138","112.01","196.33","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","149.44","59.3","","720.78","230.14","2010.94","427","126","197.69","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","149.44","59.3","","344.45","344.45","344.45","1 through 10","126","197.69","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","197.69","78.45","","1120.13","1120.13","1120.13","1 through 10","126","197.69","percent of total billed charges",""
"SCREW BONE 2.4X12MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM","SUP-ITM-10080034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","197.69","78.45","","456.17","105.33","1284.66","242","126","197.69","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","AETNA [1001]","HB CH AETNA HMO / PPO","117.78","58.3","","464.71","67.87","1012.10","221","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.78","58.3","","293.04","293.04","293.04","11","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","107.07","53","","983.89","983.89","983.89","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","117.17","58","","677.18","677.18","677.18","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","126.26","62.5","","46.58","46.58","46.58","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","147.47","73","","747.15","747.15","747.15","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.80","44.45","","1141.67","481.21","1141.67","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.80","44.45","","76.54","76.54","76.54","1 through 10","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","WELLPOINT [1015]","HB CH WELLPOINT","157.39","77.91","","273.64","94.28","1367.51","138","89.8","157.39","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.80","59.3","","720.78","230.14","2010.94","427","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","119.80","59.3","","344.45","344.45","344.45","1 through 10","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","158.48","78.45","","1120.13","1120.13","1120.13","1 through 10","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.48","78.45","","456.17","105.33","1284.66","242","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","AETNA [1001]","HB CH AETNA HMO / PPO","174.73","58.3","","464.71","67.87","1012.10","221","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.73","58.3","","293.04","293.04","293.04","11","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","158.84","53","","983.89","983.89","983.89","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","173.83","58","","677.18","677.18","677.18","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.31","62.5","","46.58","46.58","46.58","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","218.78","73","","747.15","747.15","747.15","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.22","44.45","","1141.67","481.21","1141.67","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.22","44.45","","76.54","76.54","76.54","1 through 10","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.70","224.77","WELLPOINT [1015]","HB CH WELLPOINT","233.50","77.91","","273.64","94.28","1367.51","138","133.22","233.5","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.70","224.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.72","59.3","","720.78","230.14","2010.94","427","149.85","235.11","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.70","224.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.72","59.3","","344.45","344.45","344.45","1 through 10","149.85","235.11","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.70","224.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.11","78.45","","1120.13","1120.13","1120.13","1 through 10","149.85","235.11","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.70","224.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.11","78.45","","456.17","105.33","1284.66","242","149.85","235.11","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","AETNA [1001]","HB CH AETNA HMO / PPO","210.32","58.3","","464.71","67.87","1012.10","221","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.32","58.3","","293.04","293.04","293.04","11","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.20","53","","983.89","983.89","983.89","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","209.24","58","","677.18","677.18","677.18","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","225.47","62.5","","46.58","46.58","46.58","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","263.35","73","","747.15","747.15","747.15","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.35","44.45","","1141.67","481.21","1141.67","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.35","44.45","","76.54","76.54","76.54","1 through 10","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","WELLPOINT [1015]","HB CH WELLPOINT","281.06","77.91","","273.64","94.28","1367.51","138","160.35","281.06","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","213.92","59.3","","720.78","230.14","2010.94","427","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","213.92","59.3","","344.45","344.45","344.45","1 through 10","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","283.01","78.45","","1120.13","1120.13","1120.13","1 through 10","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.01","78.45","","456.17","105.33","1284.66","242","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","AETNA [1001]","HB CH AETNA HMO / PPO","86.07","58.3","","464.71","67.87","1012.10","221","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","86.07","58.3","","293.04","293.04","293.04","11","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.24","53","","983.89","983.89","983.89","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","85.63","58","","677.18","677.18","677.18","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","92.27","62.5","","46.58","46.58","46.58","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","107.77","73","","747.15","747.15","747.15","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.62","44.45","","1141.67","481.21","1141.67","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.62","44.45","","76.54","76.54","76.54","1 through 10","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","WELLPOINT [1015]","HB CH WELLPOINT","115.02","77.91","","273.64","94.28","1367.51","138","65.62","115.02","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.54","59.3","","720.78","230.14","2010.94","427","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","87.54","59.3","","344.45","344.45","344.45","1 through 10","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","115.82","78.45","","1120.13","1120.13","1120.13","1 through 10","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","115.82","78.45","","456.17","105.33","1284.66","242","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","AETNA [1001]","HB CH AETNA HMO / PPO","158.55","58.3","","464.71","67.87","1012.10","221","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","158.55","58.3","","293.04","293.04","293.04","11","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","144.13","53","","983.89","983.89","983.89","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","157.73","58","","677.18","677.18","677.18","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","169.97","62.5","","46.58","46.58","46.58","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","747.15","747.15","747.15","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","1141.67","481.21","1141.67","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","76.54","76.54","76.54","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","WELLPOINT [1015]","HB CH WELLPOINT","211.88","77.91","","273.64","94.28","1367.51","138","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","161.27","59.3","","720.78","230.14","2010.94","427","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","161.27","59.3","","344.45","344.45","344.45","1 through 10","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","1120.13","1120.13","1120.13","1 through 10","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","456.17","105.33","1284.66","242","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","AETNA [1001]","HB CH AETNA HMO / PPO","365.47","58.3","","464.71","67.87","1012.10","221","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.47","58.3","","293.04","293.04","293.04","11","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.25","53","","983.89","983.89","983.89","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","363.59","58","","677.18","677.18","677.18","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","391.80","62.5","","46.58","46.58","46.58","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.62","73","","747.15","747.15","747.15","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.65","44.45","","1141.67","481.21","1141.67","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.65","44.45","","76.54","76.54","76.54","1 through 10","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","WELLPOINT [1015]","HB CH WELLPOINT","488.40","77.91","","273.64","94.28","1367.51","138","278.65","488.4","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.74","59.3","","720.78","230.14","2010.94","427","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","371.74","59.3","","344.45","344.45","344.45","1 through 10","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","491.79","78.45","","1120.13","1120.13","1120.13","1 through 10","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.79","78.45","","456.17","105.33","1284.66","242","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","AETNA [1001]","HB CH AETNA HMO / PPO","269.64","58.3","","464.71","67.87","1012.10","221","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","269.64","58.3","","293.04","293.04","293.04","11","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.13","53","","983.89","983.89","983.89","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","268.26","58","","677.18","677.18","677.18","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","289.07","62.5","","46.58","46.58","46.58","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","747.15","747.15","747.15","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","1141.67","481.21","1141.67","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","76.54","76.54","76.54","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","WELLPOINT [1015]","HB CH WELLPOINT","360.34","77.91","","273.64","94.28","1367.51","138","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.27","59.3","","720.78","230.14","2010.94","427","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","274.27","59.3","","344.45","344.45","344.45","1 through 10","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","1120.13","1120.13","1120.13","1 through 10","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","456.17","105.33","1284.66","242","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","AETNA [1001]","HB CH AETNA HMO / PPO","158.55","58.3","","464.71","67.87","1012.10","221","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","158.55","58.3","","293.04","293.04","293.04","11","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","144.13","53","","983.89","983.89","983.89","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","157.73","58","","677.18","677.18","677.18","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","169.97","62.5","","46.58","46.58","46.58","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","747.15","747.15","747.15","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","1141.67","481.21","1141.67","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","76.54","76.54","76.54","1 through 10","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","WELLPOINT [1015]","HB CH WELLPOINT","211.88","77.91","","273.64","94.28","1367.51","138","120.88","211.88","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","161.27","59.3","","720.78","230.14","2010.94","427","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","161.27","59.3","","344.45","344.45","344.45","1 through 10","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","1120.13","1120.13","1120.13","1 through 10","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","456.17","105.33","1284.66","242","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","464.71","67.87","1012.10","221","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","70.54","58.3","","293.04","293.04","293.04","11","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","64.12","53","","983.89","983.89","983.89","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","70.17","58","","677.18","677.18","677.18","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.62","62.5","","46.58","46.58","46.58","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","88.32","73","","747.15","747.15","747.15","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","1141.67","481.21","1141.67","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","76.54","76.54","76.54","1 through 10","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","WELLPOINT [1015]","HB CH WELLPOINT","94.26","77.91","","273.64","94.28","1367.51","138","53.78","94.26","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","720.78","230.14","2010.94","427","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","71.75","59.3","","344.45","344.45","344.45","1 through 10","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","1120.13","1120.13","1120.13","1 through 10","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","456.17","105.33","1284.66","242","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","AETNA [1001]","HB CH AETNA HMO / PPO","403.53","58.3","","464.71","67.87","1012.10","221","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","403.53","58.3","","293.04","293.04","293.04","11","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","366.84","53","","983.89","983.89","983.89","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","401.45","58","","677.18","677.18","677.18","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","432.60","62.5","","46.58","46.58","46.58","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","505.28","73","","747.15","747.15","747.15","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.67","44.45","","1141.67","481.21","1141.67","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.67","44.45","","76.54","76.54","76.54","1 through 10","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.16","519.12","WELLPOINT [1015]","HB CH WELLPOINT","539.26","77.91","","273.64","94.28","1367.51","138","307.67","539.26","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.16","519.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","410.45","59.3","","720.78","230.14","2010.94","427","346.08","543","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.16","519.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","410.45","59.3","","344.45","344.45","344.45","1 through 10","346.08","543","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.16","519.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","543.00","78.45","","1120.13","1120.13","1120.13","1 through 10","346.08","543","percent of total billed charges",""
"SCREW BONE 2.4X36MM CANNULATED COMPRESSION HEADLESS LONG THREAD TITANIUM","SUP-ITM-10096382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.16","519.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","543.00","78.45","","456.17","105.33","1284.66","242","346.08","543","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","AETNA [1001]","HB CH AETNA HMO / PPO","78.30","58.3","","464.71","67.87","1012.10","221","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.30","58.3","","293.04","293.04","293.04","11","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.18","53","","983.89","983.89","983.89","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","77.90","58","","677.18","677.18","677.18","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","83.94","62.5","","46.58","46.58","46.58","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","747.15","747.15","747.15","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","1141.67","481.21","1141.67","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","76.54","76.54","76.54","1 through 10","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","WELLPOINT [1015]","HB CH WELLPOINT","104.64","77.91","","273.64","94.28","1367.51","138","59.7","104.64","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","79.65","59.3","","720.78","230.14","2010.94","427","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","79.65","59.3","","344.45","344.45","344.45","1 through 10","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","1120.13","1120.13","1120.13","1 through 10","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","456.17","105.33","1284.66","242","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","AETNA [1001]","HB CH AETNA HMO / PPO","68.60","58.3","","464.71","67.87","1012.10","221","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","68.60","58.3","","293.04","293.04","293.04","11","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","62.36","53","","983.89","983.89","983.89","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","68.24","58","","677.18","677.18","677.18","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","73.54","62.5","","46.58","46.58","46.58","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","85.89","73","","747.15","747.15","747.15","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.30","44.45","","1141.67","481.21","1141.67","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.30","44.45","","76.54","76.54","76.54","1 through 10","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","WELLPOINT [1015]","HB CH WELLPOINT","91.67","77.91","","273.64","94.28","1367.51","138","52.3","91.67","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.77","59.3","","720.78","230.14","2010.94","427","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","69.77","59.3","","344.45","344.45","344.45","1 through 10","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","92.30","78.45","","1120.13","1120.13","1120.13","1 through 10","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.30","78.45","","456.17","105.33","1284.66","242","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","464.71","67.87","1012.10","221","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.39","58.3","","293.04","293.04","293.04","11","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","983.89","983.89","983.89","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","184.44","58","","677.18","677.18","677.18","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","198.75","62.5","","46.58","46.58","46.58","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","747.15","747.15","747.15","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","1141.67","481.21","1141.67","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","76.54","76.54","76.54","1 through 10","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","273.64","94.28","1367.51","138","141.35","247.75","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","720.78","230.14","2010.94","427","159","249.47","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","188.57","59.3","","344.45","344.45","344.45","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","1120.13","1120.13","1120.13","1 through 10","159","249.47","percent of total billed charges",""
"SCREW BONE 2.5MM 11MM HD7 NON-LOCKING CORTEX GOLD","SUP-ITM-10237453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","456.17","105.33","1284.66","242","159","249.47","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","AETNA [1001]","HB CH AETNA HMO / PPO","128.03","58.3","","464.71","67.87","1012.10","221","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","128.03","58.3","","293.04","293.04","293.04","11","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","116.39","53","","983.89","983.89","983.89","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","127.37","58","","677.18","677.18","677.18","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","137.25","62.5","","46.58","46.58","46.58","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","160.31","73","","747.15","747.15","747.15","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.61","44.45","","1141.67","481.21","1141.67","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.61","44.45","","76.54","76.54","76.54","1 through 10","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","both","","","219.60","164.70","WELLPOINT [1015]","HB CH WELLPOINT","171.09","77.91","","273.64","94.28","1367.51","138","97.61","171.09","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","219.60","164.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","130.22","59.3","","720.78","230.14","2010.94","427","109.8","172.28","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","219.60","164.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","130.22","59.3","","344.45","344.45","344.45","1 through 10","109.8","172.28","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","219.60","164.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","172.28","78.45","","1120.13","1120.13","1120.13","1 through 10","109.8","172.28","percent of total billed charges",""
"SCREW BONE 2.5MMX7MM MAXILLOFACIAL TITANIUM ALLOY EMERGENCY MAXDRIVE LAT 6AL 4V","SUP-ITM-10152607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","219.60","164.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","172.28","78.45","","456.17","105.33","1284.66","242","109.8","172.28","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","464.71","67.87","1012.10","221","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.29","58.3","","293.04","293.04","293.04","11","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","333.90","53","","983.89","983.89","983.89","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","365.40","58","","677.18","677.18","677.18","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","393.75","62.5","","46.58","46.58","46.58","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","747.15","747.15","747.15","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","1141.67","481.21","1141.67","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","76.54","76.54","76.54","1 through 10","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB CH WELLPOINT","490.83","77.91","","273.64","94.28","1367.51","138","280.04","490.83","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","373.59","59.3","","720.78","230.14","2010.94","427","315","494.24","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","373.59","59.3","","344.45","344.45","344.45","1 through 10","315","494.24","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","1120.13","1120.13","1120.13","1 through 10","315","494.24","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","456.17","105.33","1284.66","242","315","494.24","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","AETNA [1001]","HB CH AETNA HMO / PPO","341.06","58.3","","464.71","67.87","1012.10","221","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","341.06","58.3","","293.04","293.04","293.04","11","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","310.05","53","","983.89","983.89","983.89","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","339.30","58","","677.18","677.18","677.18","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","365.63","62.5","","46.58","46.58","46.58","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","427.05","73","","747.15","747.15","747.15","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","260.03","44.45","","1141.67","481.21","1141.67","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","260.03","44.45","","76.54","76.54","76.54","1 through 10","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","WELLPOINT [1015]","HB CH WELLPOINT","455.77","77.91","","273.64","94.28","1367.51","138","260.03","455.77","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.91","59.3","","720.78","230.14","2010.94","427","292.5","458.93","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","346.91","59.3","","344.45","344.45","344.45","1 through 10","292.5","458.93","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","1120.13","1120.13","1120.13","1 through 10","292.5","458.93","percent of total billed charges",""
"SCREW BONE 2.5X16MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","456.17","105.33","1284.66","242","292.5","458.93","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","AETNA [1001]","HB CH AETNA HMO / PPO","549.01","58.3","","464.71","67.87","1012.10","221","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.01","58.3","","293.04","293.04","293.04","11","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.10","53","","983.89","983.89","983.89","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","546.19","58","","677.18","677.18","677.18","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","588.56","62.5","","46.58","46.58","46.58","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","747.15","747.15","747.15","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.59","44.45","","1141.67","481.21","1141.67","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.59","44.45","","76.54","76.54","76.54","1 through 10","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","WELLPOINT [1015]","HB CH WELLPOINT","733.68","77.91","","273.64","94.28","1367.51","138","418.59","733.68","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.43","59.3","","720.78","230.14","2010.94","427","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","558.43","59.3","","344.45","344.45","344.45","1 through 10","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","738.76","78.45","","1120.13","1120.13","1120.13","1 through 10","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X16MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","738.76","78.45","","456.17","105.33","1284.66","242","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","AETNA [1001]","HB CH AETNA HMO / PPO","792.65","58.3","","464.71","67.87","1012.10","221","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","792.65","58.3","","293.04","293.04","293.04","11","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","720.59","53","","983.89","983.89","983.89","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","788.57","58","","677.18","677.18","677.18","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","849.75","62.5","","46.58","46.58","46.58","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","992.51","73","","747.15","747.15","747.15","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.34","44.45","","1141.67","481.21","1141.67","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.34","44.45","","76.54","76.54","76.54","1 through 10","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","WELLPOINT [1015]","HB CH WELLPOINT","1059.26","77.91","","273.64","94.28","1367.51","138","604.34","1059.26","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","806.24","59.3","","720.78","230.14","2010.94","427","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","806.24","59.3","","344.45","344.45","344.45","1 through 10","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1066.61","78.45","","1120.13","1120.13","1120.13","1 through 10","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 2.5X22MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10171748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1066.61","78.45","","456.17","105.33","1284.66","242","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 2.5X24MM CANNULATED TITANIUM MICRO COMPRESSION FULL THREAD VARIABLE STEPPED PITCH","SUP-ITM-10135762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","464.71","67.87","1012.10","221","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","293.04","293.04","293.04","11","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","983.89","983.89","983.89","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","815.22","58","","677.18","677.18","677.18","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","878.48","62.5","","46.58","46.58","46.58","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","747.15","747.15","747.15","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","1141.67","481.21","1141.67","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","76.54","76.54","76.54","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","273.64","94.28","1367.51","138","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","720.78","230.14","2010.94","427","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","833.50","59.3","","344.45","344.45","344.45","1 through 10","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","1120.13","1120.13","1120.13","1 through 10","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","456.17","105.33","1284.66","242","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","464.71","67.87","1012.10","221","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","293.04","293.04","293.04","11","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","983.89","983.89","983.89","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","815.22","58","","677.18","677.18","677.18","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","878.48","62.5","","46.58","46.58","46.58","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","747.15","747.15","747.15","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","1141.67","481.21","1141.67","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","76.54","76.54","76.54","1 through 10","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","273.64","94.28","1367.51","138","624.77","1095.07","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","720.78","230.14","2010.94","427","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","833.50","59.3","","344.45","344.45","344.45","1 through 10","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","1120.13","1120.13","1120.13","1 through 10","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X32MM MINI HEADLESS CANNULATED","SUP-ITM-10232426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","456.17","105.33","1284.66","242","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","464.71","67.87","1012.10","221","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.21","58.3","","293.04","293.04","293.04","11","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.37","53","","983.89","983.89","983.89","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","74.82","58","","677.18","677.18","677.18","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","80.63","62.5","","46.58","46.58","46.58","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.17","73","","747.15","747.15","747.15","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.34","44.45","","1141.67","481.21","1141.67","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.34","44.45","","76.54","76.54","76.54","1 through 10","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","WELLPOINT [1015]","HB CH WELLPOINT","100.50","77.91","","273.64","94.28","1367.51","138","57.34","100.5","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","720.78","230.14","2010.94","427","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","76.50","59.3","","344.45","344.45","344.45","1 through 10","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","1120.13","1120.13","1120.13","1 through 10","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","456.17","105.33","1284.66","242","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","AETNA [1001]","HB CH AETNA HMO / PPO","690.86","58.3","","464.71","67.87","1012.10","221","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","690.86","58.3","","293.04","293.04","293.04","11","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","628.05","53","","983.89","983.89","983.89","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","687.30","58","","677.18","677.18","677.18","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","740.63","62.5","","46.58","46.58","46.58","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","865.05","73","","747.15","747.15","747.15","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.73","44.45","","1141.67","481.21","1141.67","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.73","44.45","","76.54","76.54","76.54","1 through 10","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","WELLPOINT [1015]","HB CH WELLPOINT","923.23","77.91","","273.64","94.28","1367.51","138","526.73","923.23","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","702.71","59.3","","720.78","230.14","2010.94","427","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","702.71","59.3","","344.45","344.45","344.45","1 through 10","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","929.63","78.45","","1120.13","1120.13","1120.13","1 through 10","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","929.63","78.45","","456.17","105.33","1284.66","242","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","AETNA [1001]","HB CH AETNA HMO / PPO","232.62","58.3","","464.71","67.87","1012.10","221","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","232.62","58.3","","293.04","293.04","293.04","11","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","211.47","53","","983.89","983.89","983.89","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","231.42","58","","677.18","677.18","677.18","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","249.38","62.5","","46.58","46.58","46.58","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","747.15","747.15","747.15","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","1141.67","481.21","1141.67","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","76.54","76.54","76.54","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB CH WELLPOINT","310.86","77.91","","273.64","94.28","1367.51","138","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.61","59.3","","720.78","230.14","2010.94","427","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","236.61","59.3","","344.45","344.45","344.45","1 through 10","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","1120.13","1120.13","1120.13","1 through 10","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM RAYHACK CORTICAL SS LOCKING TRAUMA","SUP-ITM-10056838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","456.17","105.33","1284.66","242","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","AETNA [1001]","HB CH AETNA HMO / PPO","163.08","58.3","","464.71","67.87","1012.10","221","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.08","58.3","","293.04","293.04","293.04","11","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.25","53","","983.89","983.89","983.89","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","162.24","58","","677.18","677.18","677.18","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","174.83","62.5","","46.58","46.58","46.58","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","204.20","73","","747.15","747.15","747.15","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.34","44.45","","1141.67","481.21","1141.67","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.34","44.45","","76.54","76.54","76.54","1 through 10","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","both","","","279.72","209.79","WELLPOINT [1015]","HB CH WELLPOINT","217.93","77.91","","273.64","94.28","1367.51","138","124.34","217.93","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","279.72","209.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","165.87","59.3","","720.78","230.14","2010.94","427","139.86","219.44","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","279.72","209.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","165.87","59.3","","344.45","344.45","344.45","1 through 10","139.86","219.44","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","279.72","209.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","219.44","78.45","","1120.13","1120.13","1120.13","1 through 10","139.86","219.44","percent of total billed charges",""
"SCREW BONE 2.7X10MM TITANIUM LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10039749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","279.72","209.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","219.44","78.45","","456.17","105.33","1284.66","242","139.86","219.44","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","464.71","67.87","1012.10","221","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","293.04","293.04","293.04","11","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","983.89","983.89","983.89","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","277.56","58","","677.18","677.18","677.18","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","299.10","62.5","","46.58","46.58","46.58","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","747.15","747.15","747.15","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","1141.67","481.21","1141.67","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","76.54","76.54","76.54","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","273.64","94.28","1367.51","138","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","720.78","230.14","2010.94","427","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","283.79","59.3","","344.45","344.45","344.45","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","1120.13","1120.13","1120.13","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","456.17","105.33","1284.66","242","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","AETNA [1001]","HB CH AETNA HMO / PPO","697.85","58.3","","464.71","67.87","1012.10","221","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","697.85","58.3","","293.04","293.04","293.04","11","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","634.41","53","","983.89","983.89","983.89","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","694.26","58","","677.18","677.18","677.18","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","748.13","62.5","","46.58","46.58","46.58","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","873.81","73","","747.15","747.15","747.15","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","532.07","44.45","","1141.67","481.21","1141.67","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","532.07","44.45","","76.54","76.54","76.54","1 through 10","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.00","897.75","WELLPOINT [1015]","HB CH WELLPOINT","932.58","77.91","","273.64","94.28","1367.51","138","532.07","932.58","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.00","897.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","709.82","59.3","","720.78","230.14","2010.94","427","598.5","939.05","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.00","897.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","709.82","59.3","","344.45","344.45","344.45","1 through 10","598.5","939.05","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.00","897.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","939.05","78.45","","1120.13","1120.13","1120.13","1 through 10","598.5","939.05","percent of total billed charges",""
"SCREW BONE 2.7X11MM SPIN","SUP-ITM-10090147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.00","897.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","939.05","78.45","","456.17","105.33","1284.66","242","598.5","939.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","464.71","67.87","1012.10","221","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","293.04","293.04","293.04","11","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","983.89","983.89","983.89","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","513.30","58","","677.18","677.18","677.18","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","553.13","62.5","","46.58","46.58","46.58","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","747.15","747.15","747.15","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","1141.67","481.21","1141.67","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","76.54","76.54","76.54","1 through 10","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","273.64","94.28","1367.51","138","393.38","689.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","720.78","230.14","2010.94","427","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","524.81","59.3","","344.45","344.45","344.45","1 through 10","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","1120.13","1120.13","1120.13","1 through 10","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","456.17","105.33","1284.66","242","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","AETNA [1001]","HB CH AETNA HMO / PPO","61.48","58.3","","464.71","67.87","1012.10","221","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.48","58.3","","293.04","293.04","293.04","11","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.89","53","","983.89","983.89","983.89","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","61.16","58","","677.18","677.18","677.18","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.91","62.5","","46.58","46.58","46.58","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","747.15","747.15","747.15","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","1141.67","481.21","1141.67","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","76.54","76.54","76.54","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","WELLPOINT [1015]","HB CH WELLPOINT","82.16","77.91","","273.64","94.28","1367.51","138","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.53","59.3","","720.78","230.14","2010.94","427","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.53","59.3","","344.45","344.45","344.45","1 through 10","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","1120.13","1120.13","1120.13","1 through 10","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","456.17","105.33","1284.66","242","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","464.71","67.87","1012.10","221","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","120.68","58.3","","293.04","293.04","293.04","11","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","109.71","53","","983.89","983.89","983.89","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","120.06","58","","677.18","677.18","677.18","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","129.38","62.5","","46.58","46.58","46.58","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","151.11","73","","747.15","747.15","747.15","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.01","44.45","","1141.67","481.21","1141.67","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.01","44.45","","76.54","76.54","76.54","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","WELLPOINT [1015]","HB CH WELLPOINT","161.27","77.91","","273.64","94.28","1367.51","138","92.01","161.27","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.75","59.3","","720.78","230.14","2010.94","427","103.5","162.39","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","122.75","59.3","","344.45","344.45","344.45","1 through 10","103.5","162.39","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","1120.13","1120.13","1120.13","1 through 10","103.5","162.39","percent of total billed charges",""
"SCREW BONE 2.7X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","456.17","105.33","1284.66","242","103.5","162.39","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","AETNA [1001]","HB CH AETNA HMO / PPO","717.88","58.3","","464.71","67.87","1012.10","221","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","717.88","58.3","","293.04","293.04","293.04","11","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","652.62","53","","983.89","983.89","983.89","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","714.18","58","","677.18","677.18","677.18","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","769.59","62.5","","46.58","46.58","46.58","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","898.89","73","","747.15","747.15","747.15","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.34","44.45","","1141.67","481.21","1141.67","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.34","44.45","","76.54","76.54","76.54","1 through 10","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1231.35","923.51","WELLPOINT [1015]","HB CH WELLPOINT","959.34","77.91","","273.64","94.28","1367.51","138","547.34","959.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1231.35","923.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","730.19","59.3","","720.78","230.14","2010.94","427","615.68","965.99","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1231.35","923.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","730.19","59.3","","344.45","344.45","344.45","1 through 10","615.68","965.99","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1231.35","923.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","965.99","78.45","","1120.13","1120.13","1120.13","1 through 10","615.68","965.99","percent of total billed charges",""
"SCREW BONE 2.7X12MM SPIN","SUP-ITM-10090148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1231.35","923.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","965.99","78.45","","456.17","105.33","1284.66","242","615.68","965.99","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","AETNA [1001]","HB CH AETNA HMO / PPO","56.95","58.3","","464.71","67.87","1012.10","221","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","56.95","58.3","","293.04","293.04","293.04","11","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.77","53","","983.89","983.89","983.89","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","56.65","58","","677.18","677.18","677.18","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","61.05","62.5","","46.58","46.58","46.58","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","71.31","73","","747.15","747.15","747.15","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.42","44.45","","1141.67","481.21","1141.67","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.42","44.45","","76.54","76.54","76.54","1 through 10","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","WELLPOINT [1015]","HB CH WELLPOINT","76.10","77.91","","273.64","94.28","1367.51","138","43.42","76.1","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","57.92","59.3","","720.78","230.14","2010.94","427","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","57.92","59.3","","344.45","344.45","344.45","1 through 10","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","76.63","78.45","","1120.13","1120.13","1120.13","1 through 10","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.63","78.45","","456.17","105.33","1284.66","242","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","AETNA [1001]","HB CH AETNA HMO / PPO","62.77","58.3","","464.71","67.87","1012.10","221","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","62.77","58.3","","293.04","293.04","293.04","11","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.07","53","","983.89","983.89","983.89","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","62.45","58","","677.18","677.18","677.18","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","67.29","62.5","","46.58","46.58","46.58","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.60","73","","747.15","747.15","747.15","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.86","44.45","","1141.67","481.21","1141.67","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.86","44.45","","76.54","76.54","76.54","1 through 10","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","WELLPOINT [1015]","HB CH WELLPOINT","83.89","77.91","","273.64","94.28","1367.51","138","47.86","83.89","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.85","59.3","","720.78","230.14","2010.94","427","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","63.85","59.3","","344.45","344.45","344.45","1 through 10","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","1120.13","1120.13","1120.13","1 through 10","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","456.17","105.33","1284.66","242","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","AETNA [1001]","HB CH AETNA HMO / PPO","232.62","58.3","","464.71","67.87","1012.10","221","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","232.62","58.3","","293.04","293.04","293.04","11","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","211.47","53","","983.89","983.89","983.89","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","231.42","58","","677.18","677.18","677.18","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","249.38","62.5","","46.58","46.58","46.58","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","747.15","747.15","747.15","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","1141.67","481.21","1141.67","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","76.54","76.54","76.54","1 through 10","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB CH WELLPOINT","310.86","77.91","","273.64","94.28","1367.51","138","177.36","310.86","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.61","59.3","","720.78","230.14","2010.94","427","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","236.61","59.3","","344.45","344.45","344.45","1 through 10","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","1120.13","1120.13","1120.13","1 through 10","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","456.17","105.33","1284.66","242","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","464.71","67.87","1012.10","221","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","293.04","293.04","293.04","11","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","983.89","983.89","983.89","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","512.29","58","","677.18","677.18","677.18","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","552.04","62.5","","46.58","46.58","46.58","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","747.15","747.15","747.15","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","1141.67","481.21","1141.67","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","76.54","76.54","76.54","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","273.64","94.28","1367.51","138","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","720.78","230.14","2010.94","427","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.77","59.3","","344.45","344.45","344.45","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","1120.13","1120.13","1120.13","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X14MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10175757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","456.17","105.33","1284.66","242","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","AETNA [1001]","HB CH AETNA HMO / PPO","206.38","58.3","","464.71","67.87","1012.10","221","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","206.38","58.3","","293.04","293.04","293.04","11","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","187.62","53","","983.89","983.89","983.89","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","205.32","58","","677.18","677.18","677.18","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","221.25","62.5","","46.58","46.58","46.58","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","258.42","73","","747.15","747.15","747.15","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.35","44.45","","1141.67","481.21","1141.67","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.35","44.45","","76.54","76.54","76.54","1 through 10","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","WELLPOINT [1015]","HB CH WELLPOINT","275.80","77.91","","273.64","94.28","1367.51","138","157.35","275.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","209.92","59.3","","720.78","230.14","2010.94","427","177","277.71","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","209.92","59.3","","344.45","344.45","344.45","1 through 10","177","277.71","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","277.71","78.45","","1120.13","1120.13","1120.13","1 through 10","177","277.71","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL LOCKING CONGRUENT TI CS/1BX/1EA","SUP-ITM-10021374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","277.71","78.45","","456.17","105.33","1284.66","242","177","277.71","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","AETNA [1001]","HB CH AETNA HMO / PPO","117.18","58.3","","464.71","67.87","1012.10","221","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.18","58.3","","293.04","293.04","293.04","11","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.53","53","","983.89","983.89","983.89","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","116.58","58","","677.18","677.18","677.18","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","125.63","62.5","","46.58","46.58","46.58","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","146.73","73","","747.15","747.15","747.15","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","44.45","","1141.67","481.21","1141.67","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","44.45","","76.54","76.54","76.54","1 through 10","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","WELLPOINT [1015]","HB CH WELLPOINT","156.60","77.91","","273.64","94.28","1367.51","138","89.34","156.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.19","59.3","","720.78","230.14","2010.94","427","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","119.19","59.3","","344.45","344.45","344.45","1 through 10","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","157.68","78.45","","1120.13","1120.13","1120.13","1 through 10","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10021378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","157.68","78.45","","456.17","105.33","1284.66","242","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","AETNA [1001]","HB CH AETNA HMO / PPO","177.31","58.3","","464.71","67.87","1012.10","221","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","177.31","58.3","","293.04","293.04","293.04","11","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","161.19","53","","983.89","983.89","983.89","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","176.40","58","","677.18","677.18","677.18","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","190.09","62.5","","46.58","46.58","46.58","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","222.02","73","","747.15","747.15","747.15","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.19","44.45","","1141.67","481.21","1141.67","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.19","44.45","","76.54","76.54","76.54","1 through 10","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","WELLPOINT [1015]","HB CH WELLPOINT","236.96","77.91","","273.64","94.28","1367.51","138","135.19","236.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","180.36","59.3","","720.78","230.14","2010.94","427","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","180.36","59.3","","344.45","344.45","344.45","1 through 10","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","238.60","78.45","","1120.13","1120.13","1120.13","1 through 10","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","238.60","78.45","","456.17","105.33","1284.66","242","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","464.71","67.87","1012.10","221","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","293.04","293.04","293.04","11","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","983.89","983.89","983.89","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","277.56","58","","677.18","677.18","677.18","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","299.10","62.5","","46.58","46.58","46.58","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","747.15","747.15","747.15","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","1141.67","481.21","1141.67","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","76.54","76.54","76.54","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","273.64","94.28","1367.51","138","212.72","372.85","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","720.78","230.14","2010.94","427","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","283.79","59.3","","344.45","344.45","344.45","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","1120.13","1120.13","1120.13","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","456.17","105.33","1284.66","242","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","AETNA [1001]","HB CH AETNA HMO / PPO","460.63","58.3","","464.71","67.87","1012.10","221","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","460.63","58.3","","293.04","293.04","293.04","11","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","418.76","53","","983.89","983.89","983.89","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","458.26","58","","677.18","677.18","677.18","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","493.82","62.5","","46.58","46.58","46.58","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","747.15","747.15","747.15","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","1141.67","481.21","1141.67","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","76.54","76.54","76.54","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","WELLPOINT [1015]","HB CH WELLPOINT","615.57","77.91","","273.64","94.28","1367.51","138","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","468.54","59.3","","720.78","230.14","2010.94","427","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","468.54","59.3","","344.45","344.45","344.45","1 through 10","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","1120.13","1120.13","1120.13","1 through 10","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","456.17","105.33","1284.66","242","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","AETNA [1001]","HB CH AETNA HMO / PPO","269.64","58.3","","464.71","67.87","1012.10","221","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","269.64","58.3","","293.04","293.04","293.04","11","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.13","53","","983.89","983.89","983.89","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","268.26","58","","677.18","677.18","677.18","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","289.07","62.5","","46.58","46.58","46.58","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","747.15","747.15","747.15","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","1141.67","481.21","1141.67","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","76.54","76.54","76.54","1 through 10","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","WELLPOINT [1015]","HB CH WELLPOINT","360.34","77.91","","273.64","94.28","1367.51","138","205.59","360.34","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.27","59.3","","720.78","230.14","2010.94","427","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","274.27","59.3","","344.45","344.45","344.45","1 through 10","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","1120.13","1120.13","1120.13","1 through 10","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","456.17","105.33","1284.66","242","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","AETNA [1001]","HB CH AETNA HMO / PPO","460.63","58.3","","464.71","67.87","1012.10","221","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","460.63","58.3","","293.04","293.04","293.04","11","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","418.76","53","","983.89","983.89","983.89","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","458.26","58","","677.18","677.18","677.18","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","493.82","62.5","","46.58","46.58","46.58","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","747.15","747.15","747.15","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","1141.67","481.21","1141.67","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","76.54","76.54","76.54","1 through 10","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","WELLPOINT [1015]","HB CH WELLPOINT","615.57","77.91","","273.64","94.28","1367.51","138","351.2","615.57","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","468.54","59.3","","720.78","230.14","2010.94","427","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","468.54","59.3","","344.45","344.45","344.45","1 through 10","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","1120.13","1120.13","1120.13","1 through 10","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","456.17","105.33","1284.66","242","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","AETNA [1001]","HB CH AETNA HMO / PPO","66.65","58.3","","464.71","67.87","1012.10","221","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.65","58.3","","293.04","293.04","293.04","11","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.59","53","","983.89","983.89","983.89","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.31","58","","677.18","677.18","677.18","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","71.46","62.5","","46.58","46.58","46.58","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.46","73","","747.15","747.15","747.15","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.82","44.45","","1141.67","481.21","1141.67","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.82","44.45","","76.54","76.54","76.54","1 through 10","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.33","85.75","WELLPOINT [1015]","HB CH WELLPOINT","89.07","77.91","","273.64","94.28","1367.51","138","50.82","89.07","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.33","85.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.80","59.3","","720.78","230.14","2010.94","427","57.17","89.69","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.33","85.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.80","59.3","","344.45","344.45","344.45","1 through 10","57.17","89.69","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.33","85.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","89.69","78.45","","1120.13","1120.13","1120.13","1 through 10","57.17","89.69","percent of total billed charges",""
"SCREW BONE 2.7X22MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.33","85.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.69","78.45","","456.17","105.33","1284.66","242","57.17","89.69","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","AETNA [1001]","HB CH AETNA HMO / PPO","147.55","58.3","","464.71","67.87","1012.10","221","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","147.55","58.3","","293.04","293.04","293.04","11","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.13","53","","983.89","983.89","983.89","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","146.79","58","","677.18","677.18","677.18","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","158.18","62.5","","46.58","46.58","46.58","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","747.15","747.15","747.15","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","1141.67","481.21","1141.67","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","76.54","76.54","76.54","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","WELLPOINT [1015]","HB CH WELLPOINT","197.17","77.91","","273.64","94.28","1367.51","138","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.08","59.3","","720.78","230.14","2010.94","427","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","150.08","59.3","","344.45","344.45","344.45","1 through 10","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","1120.13","1120.13","1120.13","1 through 10","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","456.17","105.33","1284.66","242","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","AETNA [1001]","HB CH AETNA HMO / PPO","147.55","58.3","","464.71","67.87","1012.10","221","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","147.55","58.3","","293.04","293.04","293.04","11","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.13","53","","983.89","983.89","983.89","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","146.79","58","","677.18","677.18","677.18","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","158.18","62.5","","46.58","46.58","46.58","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","747.15","747.15","747.15","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","1141.67","481.21","1141.67","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","76.54","76.54","76.54","1 through 10","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","WELLPOINT [1015]","HB CH WELLPOINT","197.17","77.91","","273.64","94.28","1367.51","138","112.49","197.17","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.08","59.3","","720.78","230.14","2010.94","427","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","150.08","59.3","","344.45","344.45","344.45","1 through 10","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","1120.13","1120.13","1120.13","1 through 10","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","456.17","105.33","1284.66","242","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","AETNA [1001]","HB CH AETNA HMO / PPO","102.89","58.3","","464.71","67.87","1012.10","221","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","102.89","58.3","","293.04","293.04","293.04","11","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","93.54","53","","983.89","983.89","983.89","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","102.36","58","","677.18","677.18","677.18","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","110.31","62.5","","46.58","46.58","46.58","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","128.84","73","","747.15","747.15","747.15","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.45","44.45","","1141.67","481.21","1141.67","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.45","44.45","","76.54","76.54","76.54","1 through 10","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","WELLPOINT [1015]","HB CH WELLPOINT","137.50","77.91","","273.64","94.28","1367.51","138","78.45","137.5","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.66","59.3","","720.78","230.14","2010.94","427","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","104.66","59.3","","344.45","344.45","344.45","1 through 10","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","138.46","78.45","","1120.13","1120.13","1120.13","1 through 10","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.46","78.45","","456.17","105.33","1284.66","242","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","464.71","67.87","1012.10","221","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","293.04","293.04","293.04","11","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","983.89","983.89","983.89","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","512.29","58","","677.18","677.18","677.18","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","552.04","62.5","","46.58","46.58","46.58","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","747.15","747.15","747.15","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","1141.67","481.21","1141.67","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","76.54","76.54","76.54","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","273.64","94.28","1367.51","138","392.61","688.15","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","720.78","230.14","2010.94","427","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.77","59.3","","344.45","344.45","344.45","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","1120.13","1120.13","1120.13","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","456.17","105.33","1284.66","242","441.63","692.92","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","AETNA [1001]","HB CH AETNA HMO / PPO","61.48","58.3","","464.71","67.87","1012.10","221","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.48","58.3","","293.04","293.04","293.04","11","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.89","53","","983.89","983.89","983.89","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","61.16","58","","677.18","677.18","677.18","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.91","62.5","","46.58","46.58","46.58","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","747.15","747.15","747.15","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","1141.67","481.21","1141.67","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","76.54","76.54","76.54","1 through 10","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","WELLPOINT [1015]","HB CH WELLPOINT","82.16","77.91","","273.64","94.28","1367.51","138","46.87","82.16","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.53","59.3","","720.78","230.14","2010.94","427","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.53","59.3","","344.45","344.45","344.45","1 through 10","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","1120.13","1120.13","1120.13","1 through 10","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","456.17","105.33","1284.66","242","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","AETNA [1001]","HB CH AETNA HMO / PPO","71.18","58.3","","464.71","67.87","1012.10","221","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","71.18","58.3","","293.04","293.04","293.04","11","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","64.71","53","","983.89","983.89","983.89","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","70.82","58","","677.18","677.18","677.18","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","76.31","62.5","","46.58","46.58","46.58","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.13","73","","747.15","747.15","747.15","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.27","44.45","","1141.67","481.21","1141.67","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.27","44.45","","76.54","76.54","76.54","1 through 10","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","WELLPOINT [1015]","HB CH WELLPOINT","95.13","77.91","","273.64","94.28","1367.51","138","54.27","95.13","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.41","59.3","","720.78","230.14","2010.94","427","61.05","95.79","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","72.41","59.3","","344.45","344.45","344.45","1 through 10","61.05","95.79","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","95.79","78.45","","1120.13","1120.13","1120.13","1 through 10","61.05","95.79","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.79","78.45","","456.17","105.33","1284.66","242","61.05","95.79","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","AETNA [1001]","HB CH AETNA HMO / PPO","805.17","58.3","","464.71","67.87","1012.10","221","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","805.17","58.3","","293.04","293.04","293.04","11","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","731.97","53","","983.89","983.89","983.89","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","801.03","58","","677.18","677.18","677.18","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","863.18","62.5","","46.58","46.58","46.58","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1008.19","73","","747.15","747.15","747.15","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.89","44.45","","1141.67","481.21","1141.67","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.89","44.45","","76.54","76.54","76.54","1 through 10","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1381.08","1035.81","WELLPOINT [1015]","HB CH WELLPOINT","1076.00","77.91","","273.64","94.28","1367.51","138","613.89","1076","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1381.08","1035.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","818.98","59.3","","720.78","230.14","2010.94","427","690.54","1083.46","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1381.08","1035.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","818.98","59.3","","344.45","344.45","344.45","1 through 10","690.54","1083.46","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1381.08","1035.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1083.46","78.45","","1120.13","1120.13","1120.13","1 through 10","690.54","1083.46","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 FIXATION ASNIS III SS CANNULATED SELF DRILLING TAPPING THREAD LOW PROFILE","SUP-ITM-10034080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1381.08","1035.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1083.46","78.45","","456.17","105.33","1284.66","242","690.54","1083.46","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","464.71","67.87","1012.10","221","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","293.04","293.04","293.04","11","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","983.89","983.89","983.89","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","677.18","677.18","677.18","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","46.58","46.58","46.58","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","747.15","747.15","747.15","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1141.67","481.21","1141.67","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","76.54","76.54","76.54","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","273.64","94.28","1367.51","138","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","720.78","230.14","2010.94","427","900","1412.1","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","344.45","344.45","344.45","1 through 10","900","1412.1","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1120.13","1120.13","1120.13","1 through 10","900","1412.1","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","456.17","105.33","1284.66","242","900","1412.1","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","AETNA [1001]","HB CH AETNA HMO / PPO","304.33","58.3","","464.71","67.87","1012.10","221","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","304.33","58.3","","293.04","293.04","293.04","11","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.66","53","","983.89","983.89","983.89","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","302.76","58","","677.18","677.18","677.18","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","326.25","62.5","","46.58","46.58","46.58","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","747.15","747.15","747.15","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","1141.67","481.21","1141.67","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","76.54","76.54","76.54","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","WELLPOINT [1015]","HB CH WELLPOINT","406.69","77.91","","273.64","94.28","1367.51","138","232.03","406.69","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","720.78","230.14","2010.94","427","261","409.51","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","309.55","59.3","","344.45","344.45","344.45","1 through 10","261","409.51","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","1120.13","1120.13","1120.13","1 through 10","261","409.51","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","456.17","105.33","1284.66","242","261","409.51","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","464.71","67.87","1012.10","221","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","155.66","58.3","","293.04","293.04","293.04","11","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.51","53","","983.89","983.89","983.89","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","154.86","58","","677.18","677.18","677.18","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","166.88","62.5","","46.58","46.58","46.58","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","747.15","747.15","747.15","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","1141.67","481.21","1141.67","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","76.54","76.54","76.54","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","WELLPOINT [1015]","HB CH WELLPOINT","208.02","77.91","","273.64","94.28","1367.51","138","118.68","208.02","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.33","59.3","","720.78","230.14","2010.94","427","133.5","209.46","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.33","59.3","","344.45","344.45","344.45","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","1120.13","1120.13","1120.13","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10117955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","456.17","105.33","1284.66","242","133.5","209.46","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","AETNA [1001]","HB CH AETNA HMO / PPO","250.91","58.3","","464.71","67.87","1012.10","221","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","250.91","58.3","","293.04","293.04","293.04","11","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","228.10","53","","983.89","983.89","983.89","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","249.62","58","","677.18","677.18","677.18","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","268.99","62.5","","46.58","46.58","46.58","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","314.18","73","","747.15","747.15","747.15","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.30","44.45","","1141.67","481.21","1141.67","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.30","44.45","","76.54","76.54","76.54","1 through 10","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","both","","","430.38","322.78","WELLPOINT [1015]","HB CH WELLPOINT","335.31","77.91","","273.64","94.28","1367.51","138","191.3","335.31","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","430.38","322.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","255.22","59.3","","720.78","230.14","2010.94","427","215.19","337.63","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","430.38","322.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","255.22","59.3","","344.45","344.45","344.45","1 through 10","215.19","337.63","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","430.38","322.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","337.63","78.45","","1120.13","1120.13","1120.13","1 through 10","215.19","337.63","percent of total billed charges",""
"SCREW BONE 20X3.5MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","430.38","322.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","337.63","78.45","","456.17","105.33","1284.66","242","215.19","337.63","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","1530.90","1160.93","1884.08","89","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","5253.92","5253.92","5253.92","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","155.30","58","","12181.47","12181.47","12181.47","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","167.34","62.5","","1350.68","1350.68","1350.68","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","1910.74","891.94","1910.74","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","1829.79","1561.50","2617.12","88","119.01","208.6","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","1359.46","1201.30","1689.00","61","133.88","210.05","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.78","59.3","","1718.92","1718.92","1718.92","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","1910.74","1019.06","2344.84","74","133.88","210.05","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","464.71","67.87","1012.10","221","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","293.04","293.04","293.04","11","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","983.89","983.89","983.89","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.12","58","","677.18","677.18","677.18","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","71.25","62.5","","46.58","46.58","46.58","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","747.15","747.15","747.15","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","1141.67","481.21","1141.67","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","76.54","76.54","76.54","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","273.64","94.28","1367.51","138","50.67","88.82","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","720.78","230.14","2010.94","427","57","89.43","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.60","59.3","","344.45","344.45","344.45","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","1120.13","1120.13","1120.13","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 20X6.5MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10015182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","456.17","105.33","1284.66","242","57","89.43","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","AETNA [1001]","HB CH AETNA HMO / PPO","846.36","58.3","","464.71","67.87","1012.10","221","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","846.36","58.3","","293.04","293.04","293.04","11","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","769.42","53","","983.89","983.89","983.89","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","842.00","58","","677.18","677.18","677.18","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","907.33","62.5","","46.58","46.58","46.58","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1059.76","73","","747.15","747.15","747.15","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.29","44.45","","1141.67","481.21","1141.67","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.29","44.45","","76.54","76.54","76.54","1 through 10","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","WELLPOINT [1015]","HB CH WELLPOINT","1131.04","77.91","","273.64","94.28","1367.51","138","645.29","1131.04","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","860.88","59.3","","720.78","230.14","2010.94","427","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","860.88","59.3","","344.45","344.45","344.45","1 through 10","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1138.88","78.45","","1120.13","1120.13","1120.13","1 through 10","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X60 LAG NON LOCK P/THRD OMEGA PLUS","SUP-ITM-10034177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1138.88","78.45","","456.17","105.33","1284.66","242","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","AETNA [1001]","HB CH AETNA HMO / PPO","84.63","58.3","","464.71","67.87","1012.10","221","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.63","58.3","","293.04","293.04","293.04","11","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.94","53","","983.89","983.89","983.89","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","84.20","58","","677.18","677.18","677.18","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","90.73","62.5","","46.58","46.58","46.58","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.97","73","","747.15","747.15","747.15","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.53","44.45","","1141.67","481.21","1141.67","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.53","44.45","","76.54","76.54","76.54","1 through 10","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","WELLPOINT [1015]","HB CH WELLPOINT","113.10","77.91","","273.64","94.28","1367.51","138","64.53","113.1","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.09","59.3","","720.78","230.14","2010.94","427","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","86.09","59.3","","344.45","344.45","344.45","1 through 10","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","113.89","78.45","","1120.13","1120.13","1120.13","1 through 10","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.89","78.45","","456.17","105.33","1284.66","242","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","AETNA [1001]","HB CH AETNA HMO / PPO","61.25","58.3","","464.71","67.87","1012.10","221","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.25","58.3","","293.04","293.04","293.04","11","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.68","53","","983.89","983.89","983.89","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","60.93","58","","677.18","677.18","677.18","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.66","62.5","","46.58","46.58","46.58","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","747.15","747.15","747.15","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","1141.67","481.21","1141.67","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","76.54","76.54","76.54","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","WELLPOINT [1015]","HB CH WELLPOINT","81.85","77.91","","273.64","94.28","1367.51","138","46.7","81.85","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.30","59.3","","720.78","230.14","2010.94","427","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.30","59.3","","344.45","344.45","344.45","1 through 10","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","1120.13","1120.13","1120.13","1 through 10","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","456.17","105.33","1284.66","242","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","AETNA [1001]","HB CH AETNA HMO / PPO","274.59","58.3","","464.71","67.87","1012.10","221","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","274.59","58.3","","293.04","293.04","293.04","11","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","249.63","53","","983.89","983.89","983.89","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","273.18","58","","677.18","677.18","677.18","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","294.38","62.5","","46.58","46.58","46.58","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","343.83","73","","747.15","747.15","747.15","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","209.36","44.45","","1141.67","481.21","1141.67","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","209.36","44.45","","76.54","76.54","76.54","1 through 10","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","WELLPOINT [1015]","HB CH WELLPOINT","366.96","77.91","","273.64","94.28","1367.51","138","209.36","366.96","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","279.30","59.3","","720.78","230.14","2010.94","427","235.5","369.5","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","279.30","59.3","","344.45","344.45","344.45","1 through 10","235.5","369.5","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","369.50","78.45","","1120.13","1120.13","1120.13","1 through 10","235.5","369.5","percent of total billed charges",""
"SCREW BONE 22X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","369.50","78.45","","456.17","105.33","1284.66","242","235.5","369.5","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","AETNA [1001]","HB CH AETNA HMO / PPO","298.48","58.3","","464.71","67.87","1012.10","221","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","298.48","58.3","","293.04","293.04","293.04","11","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","271.35","53","","983.89","983.89","983.89","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","296.95","58","","677.18","677.18","677.18","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","319.99","62.5","","46.58","46.58","46.58","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","373.75","73","","747.15","747.15","747.15","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.58","44.45","","1141.67","481.21","1141.67","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.58","44.45","","76.54","76.54","76.54","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","WELLPOINT [1015]","HB CH WELLPOINT","398.88","77.91","","273.64","94.28","1367.51","138","227.58","398.88","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","303.60","59.3","","720.78","230.14","2010.94","427","255.99","401.65","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","303.60","59.3","","344.45","344.45","344.45","1 through 10","255.99","401.65","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","401.65","78.45","","1120.13","1120.13","1120.13","1 through 10","255.99","401.65","percent of total billed charges",""
"SCREW BONE 22X3.5MM ANCHORAGE METATARSOPHALANGEAL TITANIUM NONLOCKING T8 DRIVE","SUP-ITM-10051952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","401.65","78.45","","456.17","105.33","1284.66","242","255.99","401.65","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","AETNA [1001]","HB CH AETNA HMO / PPO","391.78","58.3","","464.71","67.87","1012.10","221","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","391.78","58.3","","293.04","293.04","293.04","11","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","356.16","53","","983.89","983.89","983.89","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","389.76","58","","677.18","677.18","677.18","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","420.00","62.5","","46.58","46.58","46.58","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","747.15","747.15","747.15","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","1141.67","481.21","1141.67","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","76.54","76.54","76.54","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","273.64","94.28","1367.51","138","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","398.50","59.3","","720.78","230.14","2010.94","427","336","527.18","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","398.50","59.3","","344.45","344.45","344.45","1 through 10","336","527.18","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","1120.13","1120.13","1120.13","1 through 10","336","527.18","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","456.17","105.33","1284.66","242","336","527.18","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","AETNA [1001]","HB CH AETNA HMO / PPO","391.78","58.3","","464.71","67.87","1012.10","221","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","391.78","58.3","","293.04","293.04","293.04","11","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","356.16","53","","983.89","983.89","983.89","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","389.76","58","","677.18","677.18","677.18","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","420.00","62.5","","46.58","46.58","46.58","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","747.15","747.15","747.15","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","1141.67","481.21","1141.67","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","76.54","76.54","76.54","1 through 10","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","273.64","94.28","1367.51","138","298.7","523.56","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","398.50","59.3","","720.78","230.14","2010.94","427","336","527.18","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","398.50","59.3","","344.45","344.45","344.45","1 through 10","336","527.18","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","1120.13","1120.13","1120.13","1 through 10","336","527.18","percent of total billed charges",""
"SCREW BONE 23X9.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","456.17","105.33","1284.66","242","336","527.18","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","464.71","67.87","1012.10","221","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","293.04","293.04","293.04","11","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","983.89","983.89","983.89","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","677.18","677.18","677.18","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","46.58","46.58","46.58","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","747.15","747.15","747.15","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","1141.67","481.21","1141.67","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","76.54","76.54","76.54","1 through 10","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","273.64","94.28","1367.51","138","900.11","1577.68","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","720.78","230.14","2010.94","427","1012.5","1588.61","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1200.83","59.3","","344.45","344.45","344.45","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SCREW BONE 24MM 4.0 STANDARD ACUTRAK 3","SUP-ITM-10327477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","456.17","105.33","1284.66","242","1012.5","1588.61","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","464.71","67.87","1012.10","221","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","293.04","293.04","293.04","11","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","983.89","983.89","983.89","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","677.18","677.18","677.18","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","46.58","46.58","46.58","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","747.15","747.15","747.15","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1141.67","481.21","1141.67","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","76.54","76.54","76.54","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","273.64","94.28","1367.51","138","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","720.78","230.14","2010.94","427","900","1412.1","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","344.45","344.45","344.45","1 through 10","900","1412.1","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1120.13","1120.13","1120.13","1 through 10","900","1412.1","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","456.17","105.33","1284.66","242","900","1412.1","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","AETNA [1001]","HB CH AETNA HMO / PPO","414.51","58.3","","464.71","67.87","1012.10","221","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","414.51","58.3","","293.04","293.04","293.04","11","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","376.83","53","","983.89","983.89","983.89","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","412.38","58","","677.18","677.18","677.18","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","444.38","62.5","","46.58","46.58","46.58","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","519.03","73","","747.15","747.15","747.15","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","1141.67","481.21","1141.67","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","76.54","76.54","76.54","1 through 10","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","WELLPOINT [1015]","HB CH WELLPOINT","553.94","77.91","","273.64","94.28","1367.51","138","316.04","553.94","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.62","59.3","","720.78","230.14","2010.94","427","355.5","557.78","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","421.62","59.3","","344.45","344.45","344.45","1 through 10","355.5","557.78","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","1120.13","1120.13","1120.13","1 through 10","355.5","557.78","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","456.17","105.33","1284.66","242","355.5","557.78","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","464.71","67.87","1012.10","221","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","293.04","293.04","293.04","11","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","983.89","983.89","983.89","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.96","58","","677.18","677.18","677.18","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","101.25","62.5","","46.58","46.58","46.58","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","747.15","747.15","747.15","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","1141.67","481.21","1141.67","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","76.54","76.54","76.54","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","273.64","94.28","1367.51","138","72.01","126.21","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","720.78","230.14","2010.94","427","81","127.09","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","96.07","59.3","","344.45","344.45","344.45","1 through 10","81","127.09","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","1120.13","1120.13","1120.13","1 through 10","81","127.09","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","456.17","105.33","1284.66","242","81","127.09","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","464.71","67.87","1012.10","221","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","293.04","293.04","293.04","11","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","983.89","983.89","983.89","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","104.40","58","","677.18","677.18","677.18","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.50","62.5","","46.58","46.58","46.58","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","747.15","747.15","747.15","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","1141.67","481.21","1141.67","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","76.54","76.54","76.54","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","273.64","94.28","1367.51","138","80.01","140.24","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","720.78","230.14","2010.94","427","90","141.21","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","106.74","59.3","","344.45","344.45","344.45","1 through 10","90","141.21","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","1120.13","1120.13","1120.13","1 through 10","90","141.21","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","456.17","105.33","1284.66","242","90","141.21","percent of total billed charges",""
"SCREW BONE 27B SPINE CERVICAL REVISION CODE SCA-CS 35 14-S","SUP-ITM-10131846","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","5530.54","5530.54","5530.54","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","AETNA [1001]","HB CH AETNA HMO / PPO","640.13","58.3","","464.71","67.87","1012.10","221","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","640.13","58.3","","293.04","293.04","293.04","11","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","581.94","53","","983.89","983.89","983.89","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","636.84","58","","677.18","677.18","677.18","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","686.25","62.5","","46.58","46.58","46.58","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","801.54","73","","747.15","747.15","747.15","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.06","44.45","","1141.67","481.21","1141.67","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.06","44.45","","76.54","76.54","76.54","1 through 10","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.00","823.50","WELLPOINT [1015]","HB CH WELLPOINT","855.45","77.91","","273.64","94.28","1367.51","138","488.06","855.45","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.11","59.3","","720.78","230.14","2010.94","427","549","861.38","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","651.11","59.3","","344.45","344.45","344.45","1 through 10","549","861.38","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","861.38","78.45","","1120.13","1120.13","1120.13","1 through 10","549","861.38","percent of total billed charges",""
"SCREW BONE 28MMX9 2.2 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 7 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.00","823.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","861.38","78.45","","456.17","105.33","1284.66","242","549","861.38","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","AETNA [1001]","HB CH AETNA HMO / PPO","88.01","58.3","","464.71","67.87","1012.10","221","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","88.01","58.3","","293.04","293.04","293.04","11","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","80.01","53","","983.89","983.89","983.89","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.56","58","","677.18","677.18","677.18","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","94.35","62.5","","46.58","46.58","46.58","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.20","73","","747.15","747.15","747.15","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.10","44.45","","1141.67","481.21","1141.67","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.10","44.45","","76.54","76.54","76.54","1 through 10","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","WELLPOINT [1015]","HB CH WELLPOINT","117.61","77.91","","273.64","94.28","1367.51","138","67.1","117.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.52","59.3","","720.78","230.14","2010.94","427","75.48","118.43","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","89.52","59.3","","344.45","344.45","344.45","1 through 10","75.48","118.43","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","118.43","78.45","","1120.13","1120.13","1120.13","1 through 10","75.48","118.43","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.43","78.45","","456.17","105.33","1284.66","242","75.48","118.43","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","AETNA [1001]","HB CH AETNA HMO / PPO","66.01","58.3","","464.71","67.87","1012.10","221","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.01","58.3","","293.04","293.04","293.04","11","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.01","53","","983.89","983.89","983.89","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","65.67","58","","677.18","677.18","677.18","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","70.76","62.5","","46.58","46.58","46.58","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","82.65","73","","747.15","747.15","747.15","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.33","44.45","","1141.67","481.21","1141.67","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.33","44.45","","76.54","76.54","76.54","1 through 10","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","WELLPOINT [1015]","HB CH WELLPOINT","88.21","77.91","","273.64","94.28","1367.51","138","50.33","88.21","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.14","59.3","","720.78","230.14","2010.94","427","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.14","59.3","","344.45","344.45","344.45","1 through 10","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","88.82","78.45","","1120.13","1120.13","1120.13","1 through 10","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.82","78.45","","456.17","105.33","1284.66","242","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","AETNA [1001]","HB CH AETNA HMO / PPO","75.71","58.3","","464.71","67.87","1012.10","221","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.71","58.3","","293.04","293.04","293.04","11","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.83","53","","983.89","983.89","983.89","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","75.32","58","","677.18","677.18","677.18","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","81.17","62.5","","46.58","46.58","46.58","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.81","73","","747.15","747.15","747.15","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.73","44.45","","1141.67","481.21","1141.67","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.73","44.45","","76.54","76.54","76.54","1 through 10","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","WELLPOINT [1015]","HB CH WELLPOINT","101.18","77.91","","273.64","94.28","1367.51","138","57.73","101.18","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.01","59.3","","720.78","230.14","2010.94","427","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","77.01","59.3","","344.45","344.45","344.45","1 through 10","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","101.88","78.45","","1120.13","1120.13","1120.13","1 through 10","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.88","78.45","","456.17","105.33","1284.66","242","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","AETNA [1001]","HB CH AETNA HMO / PPO","129.67","58.3","","464.71","67.87","1012.10","221","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","129.67","58.3","","293.04","293.04","293.04","11","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.88","53","","983.89","983.89","983.89","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","129.00","58","","677.18","677.18","677.18","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","139.01","62.5","","46.58","46.58","46.58","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","162.37","73","","747.15","747.15","747.15","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.87","44.45","","1141.67","481.21","1141.67","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.87","44.45","","76.54","76.54","76.54","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","WELLPOINT [1015]","HB CH WELLPOINT","173.29","77.91","","273.64","94.28","1367.51","138","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.90","59.3","","720.78","230.14","2010.94","427","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","131.90","59.3","","344.45","344.45","344.45","1 through 10","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","174.49","78.45","","1120.13","1120.13","1120.13","1 through 10","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X10MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.49","78.45","","456.17","105.33","1284.66","242","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","AETNA [1001]","HB CH AETNA HMO / PPO","553.05","58.3","","464.71","67.87","1012.10","221","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","553.05","58.3","","293.04","293.04","293.04","11","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","502.77","53","","983.89","983.89","983.89","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","550.21","58","","677.18","677.18","677.18","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","592.89","62.5","","46.58","46.58","46.58","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","692.50","73","","747.15","747.15","747.15","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","44.45","","1141.67","481.21","1141.67","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","44.45","","76.54","76.54","76.54","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","WELLPOINT [1015]","HB CH WELLPOINT","739.08","77.91","","273.64","94.28","1367.51","138","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","562.54","59.3","","720.78","230.14","2010.94","427","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","562.54","59.3","","344.45","344.45","344.45","1 through 10","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","744.20","78.45","","1120.13","1120.13","1120.13","1 through 10","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","744.20","78.45","","456.17","105.33","1284.66","242","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","464.71","67.87","1012.10","221","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","293.04","293.04","293.04","11","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","983.89","983.89","983.89","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.60","58","","677.18","677.18","677.18","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.50","62.5","","46.58","46.58","46.58","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","747.15","747.15","747.15","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","1141.67","481.21","1141.67","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","76.54","76.54","76.54","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","273.64","94.28","1367.51","138","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","720.78","230.14","2010.94","427","210","329.49","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.06","59.3","","344.45","344.45","344.45","1 through 10","210","329.49","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","1120.13","1120.13","1120.13","1 through 10","210","329.49","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","456.17","105.33","1284.66","242","210","329.49","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","AETNA [1001]","HB CH AETNA HMO / PPO","568.08","58.3","","464.71","67.87","1012.10","221","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","568.08","58.3","","293.04","293.04","293.04","11","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.43","53","","983.89","983.89","983.89","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","565.15","58","","677.18","677.18","677.18","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","609.00","62.5","","46.58","46.58","46.58","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","711.31","73","","747.15","747.15","747.15","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.12","44.45","","1141.67","481.21","1141.67","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.12","44.45","","76.54","76.54","76.54","1 through 10","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.40","730.80","WELLPOINT [1015]","HB CH WELLPOINT","759.16","77.91","","273.64","94.28","1367.51","138","433.12","759.16","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.40","730.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","577.82","59.3","","720.78","230.14","2010.94","427","487.2","764.42","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.40","730.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","577.82","59.3","","344.45","344.45","344.45","1 through 10","487.2","764.42","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.40","730.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","764.42","78.45","","1120.13","1120.13","1120.13","1 through 10","487.2","764.42","percent of total billed charges",""
"SCREW BONE 2X12MM TI6 TQ-SERIES QUICKSNAP","SUP-ITM-10274079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.40","730.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.42","78.45","","456.17","105.33","1284.66","242","487.2","764.42","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","AETNA [1001]","HB CH AETNA HMO / PPO","166.31","58.3","","464.71","67.87","1012.10","221","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","166.31","58.3","","293.04","293.04","293.04","11","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","151.19","53","","983.89","983.89","983.89","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","165.46","58","","677.18","677.18","677.18","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","178.29","62.5","","46.58","46.58","46.58","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","208.25","73","","747.15","747.15","747.15","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.80","44.45","","1141.67","481.21","1141.67","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.80","44.45","","76.54","76.54","76.54","1 through 10","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","WELLPOINT [1015]","HB CH WELLPOINT","222.25","77.91","","273.64","94.28","1367.51","138","126.8","222.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","169.17","59.3","","720.78","230.14","2010.94","427","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","169.17","59.3","","344.45","344.45","344.45","1 through 10","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","223.79","78.45","","1120.13","1120.13","1120.13","1 through 10","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","223.79","78.45","","456.17","105.33","1284.66","242","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","AETNA [1001]","HB CH AETNA HMO / PPO","72.48","58.3","","464.71","67.87","1012.10","221","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","72.48","58.3","","293.04","293.04","293.04","11","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.89","53","","983.89","983.89","983.89","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","72.11","58","","677.18","677.18","677.18","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","77.70","62.5","","46.58","46.58","46.58","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","90.75","73","","747.15","747.15","747.15","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.26","44.45","","1141.67","481.21","1141.67","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.26","44.45","","76.54","76.54","76.54","1 through 10","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","WELLPOINT [1015]","HB CH WELLPOINT","96.86","77.91","","273.64","94.28","1367.51","138","55.26","96.86","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.72","59.3","","720.78","230.14","2010.94","427","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","73.72","59.3","","344.45","344.45","344.45","1 through 10","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","97.53","78.45","","1120.13","1120.13","1120.13","1 through 10","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.53","78.45","","456.17","105.33","1284.66","242","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","AETNA [1001]","HB CH AETNA HMO / PPO","553.05","58.3","","464.71","67.87","1012.10","221","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","553.05","58.3","","293.04","293.04","293.04","11","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","502.77","53","","983.89","983.89","983.89","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","550.21","58","","677.18","677.18","677.18","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","592.89","62.5","","46.58","46.58","46.58","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","692.50","73","","747.15","747.15","747.15","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","44.45","","1141.67","481.21","1141.67","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","44.45","","76.54","76.54","76.54","1 through 10","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","WELLPOINT [1015]","HB CH WELLPOINT","739.08","77.91","","273.64","94.28","1367.51","138","421.67","739.08","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","562.54","59.3","","720.78","230.14","2010.94","427","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","562.54","59.3","","344.45","344.45","344.45","1 through 10","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","744.20","78.45","","1120.13","1120.13","1120.13","1 through 10","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X15MM TWIST-OFF NON STERILE","SUP-ITM-10230362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","744.20","78.45","","456.17","105.33","1284.66","242","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","AETNA [1001]","HB CH AETNA HMO / PPO","171.40","58.3","","464.71","67.87","1012.10","221","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","171.40","58.3","","293.04","293.04","293.04","11","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","155.82","53","","983.89","983.89","983.89","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","170.52","58","","677.18","677.18","677.18","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","183.75","62.5","","46.58","46.58","46.58","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","214.62","73","","747.15","747.15","747.15","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","1141.67","481.21","1141.67","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","76.54","76.54","76.54","1 through 10","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB CH WELLPOINT","229.06","77.91","","273.64","94.28","1367.51","138","130.68","229.06","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","174.34","59.3","","720.78","230.14","2010.94","427","147","230.64","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","174.34","59.3","","344.45","344.45","344.45","1 through 10","147","230.64","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","1120.13","1120.13","1120.13","1 through 10","147","230.64","percent of total billed charges",""
"SCREW BONE 2X18MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","456.17","105.33","1284.66","242","147","230.64","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","464.71","67.87","1012.10","221","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","293.04","293.04","293.04","11","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","983.89","983.89","983.89","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.60","58","","677.18","677.18","677.18","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.50","62.5","","46.58","46.58","46.58","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","747.15","747.15","747.15","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","1141.67","481.21","1141.67","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","76.54","76.54","76.54","1 through 10","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","273.64","94.28","1367.51","138","186.69","327.22","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","720.78","230.14","2010.94","427","210","329.49","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.06","59.3","","344.45","344.45","344.45","1 through 10","210","329.49","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","1120.13","1120.13","1120.13","1 through 10","210","329.49","percent of total billed charges",""
"SCREW BONE 2X28MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","456.17","105.33","1284.66","242","210","329.49","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","AETNA [1001]","HB CH AETNA HMO / PPO","122.43","58.3","","464.71","67.87","1012.10","221","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","122.43","58.3","","293.04","293.04","293.04","11","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","111.30","53","","983.89","983.89","983.89","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","121.80","58","","677.18","677.18","677.18","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","131.25","62.5","","46.58","46.58","46.58","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","747.15","747.15","747.15","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","1141.67","481.21","1141.67","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","76.54","76.54","76.54","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB CH WELLPOINT","163.61","77.91","","273.64","94.28","1367.51","138","93.35","163.61","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.53","59.3","","720.78","230.14","2010.94","427","105","164.75","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","124.53","59.3","","344.45","344.45","344.45","1 through 10","105","164.75","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","1120.13","1120.13","1120.13","1 through 10","105","164.75","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","456.17","105.33","1284.66","242","105","164.75","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","AETNA [1001]","HB CH AETNA HMO / PPO","139.13","58.3","","464.71","67.87","1012.10","221","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.13","58.3","","293.04","293.04","293.04","11","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.48","53","","983.89","983.89","983.89","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","138.42","58","","677.18","677.18","677.18","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","149.16","62.5","","46.58","46.58","46.58","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","174.21","73","","747.15","747.15","747.15","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.08","44.45","","1141.67","481.21","1141.67","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.08","44.45","","76.54","76.54","76.54","1 through 10","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","WELLPOINT [1015]","HB CH WELLPOINT","185.93","77.91","","273.64","94.28","1367.51","138","106.08","185.93","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.52","59.3","","720.78","230.14","2010.94","427","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","141.52","59.3","","344.45","344.45","344.45","1 through 10","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","187.22","78.45","","1120.13","1120.13","1120.13","1 through 10","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","187.22","78.45","","456.17","105.33","1284.66","242","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","AETNA [1001]","HB CH AETNA HMO / PPO","58.24","58.3","","464.71","67.87","1012.10","221","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","58.24","58.3","","293.04","293.04","293.04","11","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","52.95","53","","983.89","983.89","983.89","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","57.94","58","","677.18","677.18","677.18","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","62.44","62.5","","46.58","46.58","46.58","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","72.93","73","","747.15","747.15","747.15","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.41","44.45","","1141.67","481.21","1141.67","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.41","44.45","","76.54","76.54","76.54","1 through 10","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","WELLPOINT [1015]","HB CH WELLPOINT","77.83","77.91","","273.64","94.28","1367.51","138","44.41","77.83","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.24","59.3","","720.78","230.14","2010.94","427","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","59.24","59.3","","344.45","344.45","344.45","1 through 10","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","78.37","78.45","","1120.13","1120.13","1120.13","1 through 10","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","78.37","78.45","","456.17","105.33","1284.66","242","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","AETNA [1001]","HB CH AETNA HMO / PPO","129.67","58.3","","464.71","67.87","1012.10","221","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","129.67","58.3","","293.04","293.04","293.04","11","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.88","53","","983.89","983.89","983.89","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","129.00","58","","677.18","677.18","677.18","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","139.01","62.5","","46.58","46.58","46.58","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","162.37","73","","747.15","747.15","747.15","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.87","44.45","","1141.67","481.21","1141.67","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.87","44.45","","76.54","76.54","76.54","1 through 10","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","both","","","222.42","166.81","WELLPOINT [1015]","HB CH WELLPOINT","173.29","77.91","","273.64","94.28","1367.51","138","98.87","173.29","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.90","59.3","","720.78","230.14","2010.94","427","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","131.90","59.3","","344.45","344.45","344.45","1 through 10","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","174.49","78.45","","1120.13","1120.13","1120.13","1 through 10","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING CROSS PIN MP PK/5EA","SUP-ITM-10030188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","222.42","166.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.49","78.45","","456.17","105.33","1284.66","242","111.21","174.49","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","AETNA [1001]","HB CH AETNA HMO / PPO","304.33","58.3","","464.71","67.87","1012.10","221","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","304.33","58.3","","293.04","293.04","293.04","11","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.66","53","","983.89","983.89","983.89","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","302.76","58","","677.18","677.18","677.18","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","326.25","62.5","","46.58","46.58","46.58","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","747.15","747.15","747.15","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","1141.67","481.21","1141.67","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","76.54","76.54","76.54","1 through 10","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","WELLPOINT [1015]","HB CH WELLPOINT","406.69","77.91","","273.64","94.28","1367.51","138","232.03","406.69","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","720.78","230.14","2010.94","427","261","409.51","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","309.55","59.3","","344.45","344.45","344.45","1 through 10","261","409.51","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","1120.13","1120.13","1120.13","1 through 10","261","409.51","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","456.17","105.33","1284.66","242","261","409.51","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","AETNA [1001]","HB CH AETNA HMO / PPO","327.06","58.3","","464.71","67.87","1012.10","221","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","327.06","58.3","","293.04","293.04","293.04","11","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","297.33","53","","983.89","983.89","983.89","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","325.38","58","","677.18","677.18","677.18","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","350.63","62.5","","46.58","46.58","46.58","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","409.53","73","","747.15","747.15","747.15","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","1141.67","481.21","1141.67","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","76.54","76.54","76.54","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","WELLPOINT [1015]","HB CH WELLPOINT","437.08","77.91","","273.64","94.28","1367.51","138","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","332.67","59.3","","720.78","230.14","2010.94","427","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","332.67","59.3","","344.45","344.45","344.45","1 through 10","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","1120.13","1120.13","1120.13","1 through 10","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X16MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","456.17","105.33","1284.66","242","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","AETNA [1001]","HB CH AETNA HMO / PPO","327.06","58.3","","464.71","67.87","1012.10","221","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","327.06","58.3","","293.04","293.04","293.04","11","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","297.33","53","","983.89","983.89","983.89","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","325.38","58","","677.18","677.18","677.18","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","350.63","62.5","","46.58","46.58","46.58","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","409.53","73","","747.15","747.15","747.15","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","1141.67","481.21","1141.67","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","76.54","76.54","76.54","1 through 10","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","WELLPOINT [1015]","HB CH WELLPOINT","437.08","77.91","","273.64","94.28","1367.51","138","249.36","437.08","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","332.67","59.3","","720.78","230.14","2010.94","427","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","332.67","59.3","","344.45","344.45","344.45","1 through 10","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","1120.13","1120.13","1120.13","1 through 10","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X18MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","456.17","105.33","1284.66","242","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","AETNA [1001]","HB CH AETNA HMO / PPO","297.33","58.3","","464.71","67.87","1012.10","221","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","297.33","58.3","","293.04","293.04","293.04","11","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","270.30","53","","983.89","983.89","983.89","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","295.80","58","","677.18","677.18","677.18","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","318.75","62.5","","46.58","46.58","46.58","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","747.15","747.15","747.15","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","1141.67","481.21","1141.67","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","76.54","76.54","76.54","1 through 10","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","WELLPOINT [1015]","HB CH WELLPOINT","397.34","77.91","","273.64","94.28","1367.51","138","226.7","397.34","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.43","59.3","","720.78","230.14","2010.94","427","255","400.1","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","302.43","59.3","","344.45","344.45","344.45","1 through 10","255","400.1","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","1120.13","1120.13","1120.13","1 through 10","255","400.1","percent of total billed charges",""
"SCREW BONE 3.0X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","456.17","105.33","1284.66","242","255","400.1","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","464.71","67.87","1012.10","221","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","293.04","293.04","293.04","11","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","983.89","983.89","983.89","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","182.70","58","","677.18","677.18","677.18","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","196.88","62.5","","46.58","46.58","46.58","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","747.15","747.15","747.15","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","1141.67","481.21","1141.67","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","76.54","76.54","76.54","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","273.64","94.28","1367.51","138","140.02","245.42","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","720.78","230.14","2010.94","427","157.5","247.12","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","186.80","59.3","","344.45","344.45","344.45","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","1120.13","1120.13","1120.13","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW BONE 3.2MM 18 CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","456.17","105.33","1284.66","242","157.5","247.12","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","464.71","67.87","1012.10","221","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","293.04","293.04","293.04","11","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","983.89","983.89","983.89","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","155.30","58","","677.18","677.18","677.18","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","167.34","62.5","","46.58","46.58","46.58","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","747.15","747.15","747.15","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","1141.67","481.21","1141.67","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","76.54","76.54","76.54","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","273.64","94.28","1367.51","138","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","720.78","230.14","2010.94","427","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.78","59.3","","344.45","344.45","344.45","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","1120.13","1120.13","1120.13","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","456.17","105.33","1284.66","242","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","464.71","67.87","1012.10","221","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","293.04","293.04","293.04","11","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","983.89","983.89","983.89","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","155.30","58","","677.18","677.18","677.18","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","167.34","62.5","","46.58","46.58","46.58","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","747.15","747.15","747.15","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","1141.67","481.21","1141.67","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","76.54","76.54","76.54","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","273.64","94.28","1367.51","138","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","720.78","230.14","2010.94","427","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.78","59.3","","344.45","344.45","344.45","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","1120.13","1120.13","1120.13","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","456.17","105.33","1284.66","242","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","464.71","67.87","1012.10","221","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","293.04","293.04","293.04","11","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","983.89","983.89","983.89","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","155.30","58","","677.18","677.18","677.18","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","167.34","62.5","","46.58","46.58","46.58","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","747.15","747.15","747.15","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","1141.67","481.21","1141.67","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","76.54","76.54","76.54","1 through 10","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","273.64","94.28","1367.51","138","119.01","208.6","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","720.78","230.14","2010.94","427","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.78","59.3","","344.45","344.45","344.45","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","1120.13","1120.13","1120.13","1 through 10","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 35.0X4.75 LOCKING COMPREHENSIVE REVERSE TITANIUM FIXED HEX DRIVE","SUP-ITM-10202398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","456.17","105.33","1284.66","242","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB CH AETNA HMO / PPO","225.62","58.3","","464.71","67.87","1012.10","221","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","225.62","58.3","","293.04","293.04","293.04","11","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","205.11","53","","983.89","983.89","983.89","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","224.46","58","","677.18","677.18","677.18","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","241.88","62.5","","46.58","46.58","46.58","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","747.15","747.15","747.15","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.02","44.45","","1141.67","481.21","1141.67","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.02","44.45","","76.54","76.54","76.54","1 through 10","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","WELLPOINT [1015]","HB CH WELLPOINT","301.51","77.91","","273.64","94.28","1367.51","138","172.02","301.51","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.49","59.3","","720.78","230.14","2010.94","427","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","229.49","59.3","","344.45","344.45","344.45","1 through 10","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","1120.13","1120.13","1120.13","1 through 10","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","456.17","105.33","1284.66","242","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","AETNA [1001]","HB CH AETNA HMO / PPO","209.32","58.3","","464.71","67.87","1012.10","221","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.32","58.3","","293.04","293.04","293.04","11","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.29","53","","983.89","983.89","983.89","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","208.24","58","","677.18","677.18","677.18","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","224.40","62.5","","46.58","46.58","46.58","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","747.15","747.15","747.15","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","1141.67","481.21","1141.67","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","76.54","76.54","76.54","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","WELLPOINT [1015]","HB CH WELLPOINT","279.73","77.91","","273.64","94.28","1367.51","138","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.91","59.3","","720.78","230.14","2010.94","427","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","212.91","59.3","","344.45","344.45","344.45","1 through 10","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","1120.13","1120.13","1120.13","1 through 10","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","456.17","105.33","1284.66","242","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","AETNA [1001]","HB CH AETNA HMO / PPO","41.42","58.3","","464.71","67.87","1012.10","221","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","41.42","58.3","","293.04","293.04","293.04","11","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","37.65","53","","983.89","983.89","983.89","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","41.20","58","","677.18","677.18","677.18","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","44.40","62.5","","46.58","46.58","46.58","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","51.86","73","","747.15","747.15","747.15","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.58","44.45","","1141.67","481.21","1141.67","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.58","44.45","","76.54","76.54","76.54","1 through 10","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","WELLPOINT [1015]","HB CH WELLPOINT","55.35","77.91","","273.64","94.28","1367.51","138","31.58","55.35","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.13","59.3","","720.78","230.14","2010.94","427","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","42.13","59.3","","344.45","344.45","344.45","1 through 10","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","55.73","78.45","","1120.13","1120.13","1120.13","1 through 10","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.73","78.45","","456.17","105.33","1284.66","242","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","AETNA [1001]","HB CH AETNA HMO / PPO","202.04","58.3","","464.71","67.87","1012.10","221","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","202.04","58.3","","293.04","293.04","293.04","11","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","183.68","53","","983.89","983.89","983.89","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","201.00","58","","677.18","677.18","677.18","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","216.60","62.5","","46.58","46.58","46.58","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","252.99","73","","747.15","747.15","747.15","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.05","44.45","","1141.67","481.21","1141.67","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.05","44.45","","76.54","76.54","76.54","1 through 10","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","WELLPOINT [1015]","HB CH WELLPOINT","270.00","77.91","","273.64","94.28","1367.51","138","154.05","270","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","205.51","59.3","","720.78","230.14","2010.94","427","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","205.51","59.3","","344.45","344.45","344.45","1 through 10","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","271.88","78.45","","1120.13","1120.13","1120.13","1 through 10","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","271.88","78.45","","456.17","105.33","1284.66","242","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.84","58.3","","464.71","67.87","1012.10","221","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.84","58.3","","293.04","293.04","293.04","11","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.58","53","","983.89","983.89","983.89","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","46.60","58","","677.18","677.18","677.18","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","50.21","62.5","","46.58","46.58","46.58","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","747.15","747.15","747.15","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","1141.67","481.21","1141.67","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","76.54","76.54","76.54","1 through 10","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","WELLPOINT [1015]","HB CH WELLPOINT","62.59","77.91","","273.64","94.28","1367.51","138","35.71","62.59","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.64","59.3","","720.78","230.14","2010.94","427","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","47.64","59.3","","344.45","344.45","344.45","1 through 10","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","1120.13","1120.13","1120.13","1 through 10","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","456.17","105.33","1284.66","242","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","2190.90","412.50","9264.59","16","220.03","385.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","287.10","58","","1903.20","1903.20","3826.66","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","2186.25","2186.25","2186.25","32","220.03","385.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","5556.60","5556.60","5556.60","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","1955.15","885.83","3150.40","26","220.03","385.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","831.03","253.22","2394.88","18","247.5","388.33","percent of total billed charges",""
"SCREW BONE 3.5X10MM SPINE CERVICAL AVS ANCHOR C TI SELF DRILLING","SUP-ITM-10092059","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","2481.69","1563.74","8149.28","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","AETNA [1001]","HB CH AETNA HMO / PPO","126.82","58.3","","464.71","67.87","1012.10","221","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","126.82","58.3","","293.04","293.04","293.04","11","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","115.29","53","","983.89","983.89","983.89","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","126.17","58","","677.18","677.18","677.18","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","135.96","62.5","","46.58","46.58","46.58","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","158.80","73","","747.15","747.15","747.15","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.69","44.45","","1141.67","481.21","1141.67","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.69","44.45","","76.54","76.54","76.54","1 through 10","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","WELLPOINT [1015]","HB CH WELLPOINT","169.48","77.91","","273.64","94.28","1367.51","138","96.69","169.48","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.00","59.3","","720.78","230.14","2010.94","427","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","129.00","59.3","","344.45","344.45","344.45","1 through 10","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","170.65","78.45","","1120.13","1120.13","1120.13","1 through 10","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.65","78.45","","456.17","105.33","1284.66","242","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","AETNA [1001]","HB CH AETNA HMO / PPO","30.10","58.3","","464.71","67.87","1012.10","221","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","30.10","58.3","","293.04","293.04","293.04","11","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","27.36","53","","983.89","983.89","983.89","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","29.95","58","","677.18","677.18","677.18","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","32.27","62.5","","46.58","46.58","46.58","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","37.69","73","","747.15","747.15","747.15","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.95","44.45","","1141.67","481.21","1141.67","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.95","44.45","","76.54","76.54","76.54","1 through 10","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","WELLPOINT [1015]","HB CH WELLPOINT","40.22","77.91","","273.64","94.28","1367.51","138","22.95","40.22","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.62","59.3","","720.78","230.14","2010.94","427","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","30.62","59.3","","344.45","344.45","344.45","1 through 10","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","40.50","78.45","","1120.13","1120.13","1120.13","1 through 10","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.50","78.45","","456.17","105.33","1284.66","242","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","AETNA [1001]","HB CH AETNA HMO / PPO","42.06","58.3","","464.71","67.87","1012.10","221","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","42.06","58.3","","293.04","293.04","293.04","11","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","38.24","53","","983.89","983.89","983.89","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","41.85","58","","677.18","677.18","677.18","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","45.09","62.5","","46.58","46.58","46.58","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","52.67","73","","747.15","747.15","747.15","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.07","44.45","","1141.67","481.21","1141.67","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.07","44.45","","76.54","76.54","76.54","1 through 10","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","WELLPOINT [1015]","HB CH WELLPOINT","56.21","77.91","","273.64","94.28","1367.51","138","32.07","56.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.78","59.3","","720.78","230.14","2010.94","427","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","42.78","59.3","","344.45","344.45","344.45","1 through 10","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","56.60","78.45","","1120.13","1120.13","1120.13","1 through 10","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.60","78.45","","456.17","105.33","1284.66","242","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","AETNA [1001]","HB CH AETNA HMO / PPO","188.96","58.3","","464.71","67.87","1012.10","221","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","188.96","58.3","","293.04","293.04","293.04","11","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","171.78","53","","983.89","983.89","983.89","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","187.99","58","","677.18","677.18","677.18","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","202.58","62.5","","46.58","46.58","46.58","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","236.61","73","","747.15","747.15","747.15","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.07","44.45","","1141.67","481.21","1141.67","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.07","44.45","","76.54","76.54","76.54","1 through 10","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","WELLPOINT [1015]","HB CH WELLPOINT","252.52","77.91","","273.64","94.28","1367.51","138","144.07","252.52","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","192.20","59.3","","720.78","230.14","2010.94","427","162.06","254.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","192.20","59.3","","344.45","344.45","344.45","1 through 10","162.06","254.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","254.27","78.45","","1120.13","1120.13","1120.13","1 through 10","162.06","254.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.27","78.45","","456.17","105.33","1284.66","242","162.06","254.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","464.71","67.87","1012.10","221","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","293.04","293.04","293.04","11","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","983.89","983.89","983.89","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","130.50","58","","677.18","677.18","677.18","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","140.63","62.5","","46.58","46.58","46.58","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","747.15","747.15","747.15","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","1141.67","481.21","1141.67","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","76.54","76.54","76.54","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","273.64","94.28","1367.51","138","100.01","175.3","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","720.78","230.14","2010.94","427","112.5","176.51","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","133.43","59.3","","344.45","344.45","344.45","1 through 10","112.5","176.51","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","1120.13","1120.13","1120.13","1 through 10","112.5","176.51","percent of total billed charges",""
"SCREW BONE 3.5X12MM TITANIUM SELF TAPPING VARIABLE ANGLE 8427-3512","SUP-ITM-10146122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","456.17","105.33","1284.66","242","112.5","176.51","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","AETNA [1001]","HB CH AETNA HMO / PPO","83.64","58.3","","464.71","67.87","1012.10","221","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","83.64","58.3","","293.04","293.04","293.04","11","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.03","53","","983.89","983.89","983.89","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","83.21","58","","677.18","677.18","677.18","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","89.66","62.5","","46.58","46.58","46.58","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","104.73","73","","747.15","747.15","747.15","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.77","44.45","","1141.67","481.21","1141.67","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.77","44.45","","76.54","76.54","76.54","1 through 10","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.46","107.59","WELLPOINT [1015]","HB CH WELLPOINT","111.77","77.91","","273.64","94.28","1367.51","138","63.77","111.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.46","107.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.07","59.3","","720.78","230.14","2010.94","427","71.73","112.54","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.46","107.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","85.07","59.3","","344.45","344.45","344.45","1 through 10","71.73","112.54","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.46","107.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","112.54","78.45","","1120.13","1120.13","1120.13","1 through 10","71.73","112.54","percent of total billed charges",""
"SCREW BONE 3.5X12MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.46","107.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.54","78.45","","456.17","105.33","1284.66","242","71.73","112.54","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","AETNA [1001]","HB CH AETNA HMO / PPO","144.29","58.3","","464.71","67.87","1012.10","221","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.29","58.3","","293.04","293.04","293.04","11","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.18","53","","983.89","983.89","983.89","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","143.55","58","","677.18","677.18","677.18","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","154.69","62.5","","46.58","46.58","46.58","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","180.68","73","","747.15","747.15","747.15","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.01","44.45","","1141.67","481.21","1141.67","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.01","44.45","","76.54","76.54","76.54","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","WELLPOINT [1015]","HB CH WELLPOINT","192.83","77.91","","273.64","94.28","1367.51","138","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.77","59.3","","720.78","230.14","2010.94","427","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","146.77","59.3","","344.45","344.45","344.45","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","194.16","78.45","","1120.13","1120.13","1120.13","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.16","78.45","","456.17","105.33","1284.66","242","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","464.71","67.87","1012.10","221","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","120.68","58.3","","293.04","293.04","293.04","11","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","109.71","53","","983.89","983.89","983.89","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","120.06","58","","677.18","677.18","677.18","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","129.38","62.5","","46.58","46.58","46.58","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","151.11","73","","747.15","747.15","747.15","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.01","44.45","","1141.67","481.21","1141.67","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.01","44.45","","76.54","76.54","76.54","1 through 10","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","WELLPOINT [1015]","HB CH WELLPOINT","161.27","77.91","","273.64","94.28","1367.51","138","92.01","161.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.75","59.3","","720.78","230.14","2010.94","427","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","122.75","59.3","","344.45","344.45","344.45","1 through 10","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","1120.13","1120.13","1120.13","1 through 10","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","456.17","105.33","1284.66","242","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","AETNA [1001]","HB CH AETNA HMO / PPO","249.04","58.3","","464.71","67.87","1012.10","221","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","249.04","58.3","","293.04","293.04","293.04","11","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","226.40","53","","983.89","983.89","983.89","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","247.76","58","","677.18","677.18","677.18","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","266.98","62.5","","46.58","46.58","46.58","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","311.83","73","","747.15","747.15","747.15","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.88","44.45","","1141.67","481.21","1141.67","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.88","44.45","","76.54","76.54","76.54","1 through 10","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","WELLPOINT [1015]","HB CH WELLPOINT","332.81","77.91","","273.64","94.28","1367.51","138","189.88","332.81","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","253.31","59.3","","720.78","230.14","2010.94","427","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","253.31","59.3","","344.45","344.45","344.45","1 through 10","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","335.11","78.45","","1120.13","1120.13","1120.13","1 through 10","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X14MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10115540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","335.11","78.45","","456.17","105.33","1284.66","242","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","AETNA [1001]","HB CH AETNA HMO / PPO","144.29","58.3","","464.71","67.87","1012.10","221","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.29","58.3","","293.04","293.04","293.04","11","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.18","53","","983.89","983.89","983.89","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","143.55","58","","677.18","677.18","677.18","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","154.69","62.5","","46.58","46.58","46.58","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","180.68","73","","747.15","747.15","747.15","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.01","44.45","","1141.67","481.21","1141.67","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.01","44.45","","76.54","76.54","76.54","1 through 10","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.50","185.62","WELLPOINT [1015]","HB CH WELLPOINT","192.83","77.91","","273.64","94.28","1367.51","138","110.01","192.83","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.77","59.3","","720.78","230.14","2010.94","427","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","146.77","59.3","","344.45","344.45","344.45","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","194.16","78.45","","1120.13","1120.13","1120.13","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X15MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10164875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.16","78.45","","456.17","105.33","1284.66","242","123.75","194.16","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","AETNA [1001]","HB CH AETNA HMO / PPO","33.65","58.3","","464.71","67.87","1012.10","221","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","33.65","58.3","","293.04","293.04","293.04","11","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.59","53","","983.89","983.89","983.89","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","33.48","58","","677.18","677.18","677.18","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","36.08","62.5","","46.58","46.58","46.58","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","42.14","73","","747.15","747.15","747.15","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.66","44.45","","1141.67","481.21","1141.67","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.66","44.45","","76.54","76.54","76.54","1 through 10","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.72","43.29","WELLPOINT [1015]","HB CH WELLPOINT","44.97","77.91","","273.64","94.28","1367.51","138","25.66","44.97","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.72","43.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.23","59.3","","720.78","230.14","2010.94","427","28.86","45.28","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.72","43.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","34.23","59.3","","344.45","344.45","344.45","1 through 10","28.86","45.28","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.72","43.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","45.28","78.45","","1120.13","1120.13","1120.13","1 through 10","28.86","45.28","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.72","43.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.28","78.45","","456.17","105.33","1284.66","242","28.86","45.28","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","AETNA [1001]","HB CH AETNA HMO / PPO","95.48","58.3","","464.71","67.87","1012.10","221","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","95.48","58.3","","293.04","293.04","293.04","11","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","86.80","53","","983.89","983.89","983.89","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","94.99","58","","677.18","677.18","677.18","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","102.36","62.5","","46.58","46.58","46.58","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","747.15","747.15","747.15","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","1141.67","481.21","1141.67","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","76.54","76.54","76.54","1 through 10","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","WELLPOINT [1015]","HB CH WELLPOINT","127.59","77.91","","273.64","94.28","1367.51","138","72.8","127.59","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.12","59.3","","720.78","230.14","2010.94","427","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","97.12","59.3","","344.45","344.45","344.45","1 through 10","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","1120.13","1120.13","1120.13","1 through 10","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","456.17","105.33","1284.66","242","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","AETNA [1001]","HB CH AETNA HMO / PPO","45.30","58.3","","464.71","67.87","1012.10","221","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.30","58.3","","293.04","293.04","293.04","11","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.18","53","","983.89","983.89","983.89","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","45.07","58","","677.18","677.18","677.18","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","48.56","62.5","","46.58","46.58","46.58","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.72","73","","747.15","747.15","747.15","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.54","44.45","","1141.67","481.21","1141.67","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.54","44.45","","76.54","76.54","76.54","1 through 10","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","WELLPOINT [1015]","HB CH WELLPOINT","60.54","77.91","","273.64","94.28","1367.51","138","34.54","60.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.08","59.3","","720.78","230.14","2010.94","427","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","46.08","59.3","","344.45","344.45","344.45","1 through 10","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","60.96","78.45","","1120.13","1120.13","1120.13","1 through 10","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL SELF TAPPING SMALL FRAGMENT TITANIUM","SUP-ITM-10013699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.96","78.45","","456.17","105.33","1284.66","242","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","AETNA [1001]","HB CH AETNA HMO / PPO","2164.39","58.3","","464.71","67.87","1012.10","221","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2164.39","58.3","","293.04","293.04","293.04","11","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1967.63","53","","983.89","983.89","983.89","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2153.25","58","","677.18","677.18","677.18","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2320.31","62.5","","46.58","46.58","46.58","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2710.13","73","","747.15","747.15","747.15","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.21","44.45","","1141.67","481.21","1141.67","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.21","44.45","","76.54","76.54","76.54","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","WELLPOINT [1015]","HB CH WELLPOINT","2892.41","77.91","","273.64","94.28","1367.51","138","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2201.51","59.3","","720.78","230.14","2010.94","427","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2201.51","59.3","","344.45","344.45","344.45","1 through 10","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2912.46","78.45","","1120.13","1120.13","1120.13","1 through 10","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 3.5X18MM HEADLESS COMPRESSION","SUP-ITM-10307322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2912.46","78.45","","456.17","105.33","1284.66","242","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","AETNA [1001]","HB CH AETNA HMO / PPO","481.22","58.3","","464.71","67.87","1012.10","221","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","481.22","58.3","","293.04","293.04","293.04","11","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.47","53","","983.89","983.89","983.89","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.74","58","","677.18","677.18","677.18","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.89","62.5","","46.58","46.58","46.58","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.56","73","","747.15","747.15","747.15","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.90","44.45","","1141.67","481.21","1141.67","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.90","44.45","","76.54","76.54","76.54","1 through 10","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","WELLPOINT [1015]","HB CH WELLPOINT","643.08","77.91","","273.64","94.28","1367.51","138","366.9","643.08","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.47","59.3","","720.78","230.14","2010.94","427","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.47","59.3","","344.45","344.45","344.45","1 through 10","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.54","78.45","","1120.13","1120.13","1120.13","1 through 10","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.54","78.45","","456.17","105.33","1284.66","242","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","AETNA [1001]","HB CH AETNA HMO / PPO","1252.28","58.3","","464.71","67.87","1012.10","221","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1252.28","58.3","","293.04","293.04","293.04","11","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1138.44","53","","983.89","983.89","983.89","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1245.84","58","","677.18","677.18","677.18","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1342.50","62.5","","46.58","46.58","46.58","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1568.04","73","","747.15","747.15","747.15","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.79","44.45","","1141.67","481.21","1141.67","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.79","44.45","","76.54","76.54","76.54","1 through 10","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","WELLPOINT [1015]","HB CH WELLPOINT","1673.51","77.91","","273.64","94.28","1367.51","138","954.79","1673.51","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1273.76","59.3","","720.78","230.14","2010.94","427","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1273.76","59.3","","344.45","344.45","344.45","1 through 10","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1685.11","78.45","","1120.13","1120.13","1120.13","1 through 10","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X20MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1685.11","78.45","","456.17","105.33","1284.66","242","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","464.71","67.87","1012.10","221","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","293.04","293.04","293.04","11","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","983.89","983.89","983.89","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","512.29","58","","677.18","677.18","677.18","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","552.04","62.5","","46.58","46.58","46.58","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","747.15","747.15","747.15","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","1141.67","481.21","1141.67","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","76.54","76.54","76.54","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","273.64","94.28","1367.51","138","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","720.78","230.14","2010.94","427","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.77","59.3","","344.45","344.45","344.45","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","1120.13","1120.13","1120.13","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","456.17","105.33","1284.66","242","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","464.71","67.87","1012.10","221","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","293.04","293.04","293.04","11","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","983.89","983.89","983.89","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","277.56","58","","677.18","677.18","677.18","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","299.10","62.5","","46.58","46.58","46.58","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","747.15","747.15","747.15","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","1141.67","481.21","1141.67","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","76.54","76.54","76.54","1 through 10","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","273.64","94.28","1367.51","138","212.72","372.85","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","720.78","230.14","2010.94","427","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","283.79","59.3","","344.45","344.45","344.45","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","1120.13","1120.13","1120.13","1 through 10","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","456.17","105.33","1284.66","242","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","AETNA [1001]","HB CH AETNA HMO / PPO","285.09","58.3","","464.71","67.87","1012.10","221","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","285.09","58.3","","293.04","293.04","293.04","11","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","259.17","53","","983.89","983.89","983.89","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","283.62","58","","677.18","677.18","677.18","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","305.63","62.5","","46.58","46.58","46.58","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.97","73","","747.15","747.15","747.15","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.36","44.45","","1141.67","481.21","1141.67","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.36","44.45","","76.54","76.54","76.54","1 through 10","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","WELLPOINT [1015]","HB CH WELLPOINT","380.98","77.91","","273.64","94.28","1367.51","138","217.36","380.98","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.98","59.3","","720.78","230.14","2010.94","427","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","289.98","59.3","","344.45","344.45","344.45","1 through 10","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","383.62","78.45","","1120.13","1120.13","1120.13","1 through 10","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.62","78.45","","456.17","105.33","1284.66","242","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","AETNA [1001]","HB CH AETNA HMO / PPO","170.20","58.3","","464.71","67.87","1012.10","221","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","170.20","58.3","","293.04","293.04","293.04","11","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.72","53","","983.89","983.89","983.89","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","169.32","58","","677.18","677.18","677.18","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","182.46","62.5","","46.58","46.58","46.58","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","747.15","747.15","747.15","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","1141.67","481.21","1141.67","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","76.54","76.54","76.54","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","WELLPOINT [1015]","HB CH WELLPOINT","227.44","77.91","","273.64","94.28","1367.51","138","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.11","59.3","","720.78","230.14","2010.94","427","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","173.11","59.3","","344.45","344.45","344.45","1 through 10","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","1120.13","1120.13","1120.13","1 through 10","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","456.17","105.33","1284.66","242","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","AETNA [1001]","HB CH AETNA HMO / PPO","31.06","58.3","","464.71","67.87","1012.10","221","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.06","58.3","","293.04","293.04","293.04","11","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.24","53","","983.89","983.89","983.89","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","30.90","58","","677.18","677.18","677.18","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33.30","62.5","","46.58","46.58","46.58","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","38.89","73","","747.15","747.15","747.15","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.68","44.45","","1141.67","481.21","1141.67","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.68","44.45","","76.54","76.54","76.54","1 through 10","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","WELLPOINT [1015]","HB CH WELLPOINT","41.51","77.91","","273.64","94.28","1367.51","138","23.68","41.51","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.60","59.3","","720.78","230.14","2010.94","427","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","31.60","59.3","","344.45","344.45","344.45","1 through 10","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","41.80","78.45","","1120.13","1120.13","1120.13","1 through 10","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","41.80","78.45","","456.17","105.33","1284.66","242","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","AETNA [1001]","HB CH AETNA HMO / PPO","272.84","58.3","","464.71","67.87","1012.10","221","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","272.84","58.3","","293.04","293.04","293.04","11","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","248.04","53","","983.89","983.89","983.89","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","271.44","58","","677.18","677.18","677.18","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","292.50","62.5","","46.58","46.58","46.58","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","341.64","73","","747.15","747.15","747.15","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.03","44.45","","1141.67","481.21","1141.67","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.03","44.45","","76.54","76.54","76.54","1 through 10","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","WELLPOINT [1015]","HB CH WELLPOINT","364.62","77.91","","273.64","94.28","1367.51","138","208.03","364.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","277.52","59.3","","720.78","230.14","2010.94","427","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","277.52","59.3","","344.45","344.45","344.45","1 through 10","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","367.15","78.45","","1120.13","1120.13","1120.13","1 through 10","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X32MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","367.15","78.45","","456.17","105.33","1284.66","242","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","AETNA [1001]","HB CH AETNA HMO / PPO","93.62","58.3","","464.71","67.87","1012.10","221","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","93.62","58.3","","293.04","293.04","293.04","11","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.11","53","","983.89","983.89","983.89","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.14","58","","677.18","677.18","677.18","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","100.37","62.5","","46.58","46.58","46.58","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","117.23","73","","747.15","747.15","747.15","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.38","44.45","","1141.67","481.21","1141.67","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.38","44.45","","76.54","76.54","76.54","1 through 10","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.59","120.44","WELLPOINT [1015]","HB CH WELLPOINT","125.12","77.91","","273.64","94.28","1367.51","138","71.38","125.12","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.59","120.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.23","59.3","","720.78","230.14","2010.94","427","80.3","125.98","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.59","120.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","95.23","59.3","","344.45","344.45","344.45","1 through 10","80.3","125.98","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.59","120.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","125.98","78.45","","1120.13","1120.13","1120.13","1 through 10","80.3","125.98","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.59","120.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","125.98","78.45","","456.17","105.33","1284.66","242","80.3","125.98","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","AETNA [1001]","HB CH AETNA HMO / PPO","209.32","58.3","","464.71","67.87","1012.10","221","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.32","58.3","","293.04","293.04","293.04","11","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.29","53","","983.89","983.89","983.89","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","208.24","58","","677.18","677.18","677.18","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","224.40","62.5","","46.58","46.58","46.58","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","747.15","747.15","747.15","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","1141.67","481.21","1141.67","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","76.54","76.54","76.54","1 through 10","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","WELLPOINT [1015]","HB CH WELLPOINT","279.73","77.91","","273.64","94.28","1367.51","138","159.59","279.73","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.91","59.3","","720.78","230.14","2010.94","427","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","212.91","59.3","","344.45","344.45","344.45","1 through 10","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","1120.13","1120.13","1120.13","1 through 10","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","456.17","105.33","1284.66","242","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","464.71","67.87","1012.10","221","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","293.04","293.04","293.04","11","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","983.89","983.89","983.89","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1383.30","58","","677.18","677.18","677.18","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1490.63","62.5","","46.58","46.58","46.58","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","747.15","747.15","747.15","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","1141.67","481.21","1141.67","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","76.54","76.54","76.54","1 through 10","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","273.64","94.28","1367.51","138","1060.13","1858.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","720.78","230.14","2010.94","427","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1414.31","59.3","","344.45","344.45","344.45","1 through 10","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","1120.13","1120.13","1120.13","1 through 10","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 3.5X36MM FULL THREAD BEVELED","SUP-ITM-10317880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","456.17","105.33","1284.66","242","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","AETNA [1001]","HB CH AETNA HMO / PPO","198.16","58.3","","464.71","67.87","1012.10","221","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.16","58.3","","293.04","293.04","293.04","11","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.15","53","","983.89","983.89","983.89","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","197.14","58","","677.18","677.18","677.18","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","212.44","62.5","","46.58","46.58","46.58","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","747.15","747.15","747.15","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","1141.67","481.21","1141.67","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","76.54","76.54","76.54","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","WELLPOINT [1015]","HB CH WELLPOINT","264.82","77.91","","273.64","94.28","1367.51","138","151.09","264.82","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.56","59.3","","720.78","230.14","2010.94","427","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","201.56","59.3","","344.45","344.45","344.45","1 through 10","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","1120.13","1120.13","1120.13","1 through 10","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","456.17","105.33","1284.66","242","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","AETNA [1001]","HB CH AETNA HMO / PPO","75.66","58.3","","464.71","67.87","1012.10","221","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.66","58.3","","293.04","293.04","293.04","11","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.78","53","","983.89","983.89","983.89","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","75.27","58","","677.18","677.18","677.18","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","81.11","62.5","","46.58","46.58","46.58","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.74","73","","747.15","747.15","747.15","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.69","44.45","","1141.67","481.21","1141.67","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.69","44.45","","76.54","76.54","76.54","1 through 10","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","WELLPOINT [1015]","HB CH WELLPOINT","101.11","77.91","","273.64","94.28","1367.51","138","57.69","101.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.96","59.3","","720.78","230.14","2010.94","427","64.89","101.81","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","76.96","59.3","","344.45","344.45","344.45","1 through 10","64.89","101.81","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","101.81","78.45","","1120.13","1120.13","1120.13","1 through 10","64.89","101.81","percent of total billed charges",""
"SCREW BONE 3.5X40MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.81","78.45","","456.17","105.33","1284.66","242","64.89","101.81","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","AETNA [1001]","HB CH AETNA HMO / PPO","314.82","58.3","","464.71","67.87","1012.10","221","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","314.82","58.3","","293.04","293.04","293.04","11","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","286.20","53","","983.89","983.89","983.89","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","313.20","58","","677.18","677.18","677.18","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","337.50","62.5","","46.58","46.58","46.58","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","394.20","73","","747.15","747.15","747.15","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.03","44.45","","1141.67","481.21","1141.67","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.03","44.45","","76.54","76.54","76.54","1 through 10","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","WELLPOINT [1015]","HB CH WELLPOINT","420.71","77.91","","273.64","94.28","1367.51","138","240.03","420.71","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","320.22","59.3","","720.78","230.14","2010.94","427","270","423.63","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","320.22","59.3","","344.45","344.45","344.45","1 through 10","270","423.63","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","423.63","78.45","","1120.13","1120.13","1120.13","1 through 10","270","423.63","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM COMPRESSION TITANIUM","SUP-ITM-10198166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","423.63","78.45","","456.17","105.33","1284.66","242","270","423.63","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","AETNA [1001]","HB CH AETNA HMO / PPO","363.62","58.3","","464.71","67.87","1012.10","221","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.62","58.3","","293.04","293.04","293.04","11","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.56","53","","983.89","983.89","983.89","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","361.75","58","","677.18","677.18","677.18","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","389.81","62.5","","46.58","46.58","46.58","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.30","73","","747.15","747.15","747.15","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.23","44.45","","1141.67","481.21","1141.67","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.23","44.45","","76.54","76.54","76.54","1 through 10","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","WELLPOINT [1015]","HB CH WELLPOINT","485.92","77.91","","273.64","94.28","1367.51","138","277.23","485.92","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","369.85","59.3","","720.78","230.14","2010.94","427","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","369.85","59.3","","344.45","344.45","344.45","1 through 10","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","489.29","78.45","","1120.13","1120.13","1120.13","1 through 10","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.29","78.45","","456.17","105.33","1284.66","242","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","AETNA [1001]","HB CH AETNA HMO / PPO","141.67","58.3","","464.71","67.87","1012.10","221","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","141.67","58.3","","293.04","293.04","293.04","11","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","128.79","53","","983.89","983.89","983.89","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","140.94","58","","677.18","677.18","677.18","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","151.88","62.5","","46.58","46.58","46.58","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","177.39","73","","747.15","747.15","747.15","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.01","44.45","","1141.67","481.21","1141.67","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.01","44.45","","76.54","76.54","76.54","1 through 10","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.00","182.25","WELLPOINT [1015]","HB CH WELLPOINT","189.32","77.91","","273.64","94.28","1367.51","138","108.01","189.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.00","182.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.10","59.3","","720.78","230.14","2010.94","427","121.5","190.63","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","144.10","59.3","","344.45","344.45","344.45","1 through 10","121.5","190.63","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","190.63","78.45","","1120.13","1120.13","1120.13","1 through 10","121.5","190.63","percent of total billed charges",""
"SCREW BONE 3.5X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10030628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","190.63","78.45","","456.17","105.33","1284.66","242","121.5","190.63","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","464.71","67.87","1012.10","221","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","293.04","293.04","293.04","11","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","983.89","983.89","983.89","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","512.29","58","","677.18","677.18","677.18","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","552.04","62.5","","46.58","46.58","46.58","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","747.15","747.15","747.15","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","1141.67","481.21","1141.67","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","76.54","76.54","76.54","1 through 10","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","273.64","94.28","1367.51","138","392.61","688.15","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","720.78","230.14","2010.94","427","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","523.77","59.3","","344.45","344.45","344.45","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","1120.13","1120.13","1120.13","1 through 10","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X50MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","456.17","105.33","1284.66","242","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","AETNA [1001]","HB CH AETNA HMO / PPO","228.63","58.3","","464.71","67.87","1012.10","221","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","228.63","58.3","","293.04","293.04","293.04","11","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.84","53","","983.89","983.89","983.89","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","227.45","58","","677.18","677.18","677.18","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","245.10","62.5","","46.58","46.58","46.58","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.28","73","","747.15","747.15","747.15","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.32","44.45","","1141.67","481.21","1141.67","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.32","44.45","","76.54","76.54","76.54","1 through 10","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","WELLPOINT [1015]","HB CH WELLPOINT","305.53","77.91","","273.64","94.28","1367.51","138","174.32","305.53","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.55","59.3","","720.78","230.14","2010.94","427","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","232.55","59.3","","344.45","344.45","344.45","1 through 10","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","307.65","78.45","","1120.13","1120.13","1120.13","1 through 10","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.65","78.45","","456.17","105.33","1284.66","242","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","AETNA [1001]","HB CH AETNA HMO / PPO","170.20","58.3","","464.71","67.87","1012.10","221","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","170.20","58.3","","293.04","293.04","293.04","11","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.72","53","","983.89","983.89","983.89","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","169.32","58","","677.18","677.18","677.18","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","182.46","62.5","","46.58","46.58","46.58","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","747.15","747.15","747.15","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","1141.67","481.21","1141.67","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","76.54","76.54","76.54","1 through 10","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","WELLPOINT [1015]","HB CH WELLPOINT","227.44","77.91","","273.64","94.28","1367.51","138","129.76","227.44","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.11","59.3","","720.78","230.14","2010.94","427","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","173.11","59.3","","344.45","344.45","344.45","1 through 10","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","1120.13","1120.13","1120.13","1 through 10","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","456.17","105.33","1284.66","242","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","AETNA [1001]","HB CH AETNA HMO / PPO","227.13","58.3","","464.71","67.87","1012.10","221","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.13","58.3","","293.04","293.04","293.04","11","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.48","53","","983.89","983.89","983.89","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","225.96","58","","677.18","677.18","677.18","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","243.49","62.5","","46.58","46.58","46.58","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.39","73","","747.15","747.15","747.15","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.17","44.45","","1141.67","481.21","1141.67","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.17","44.45","","76.54","76.54","76.54","1 through 10","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","WELLPOINT [1015]","HB CH WELLPOINT","303.52","77.91","","273.64","94.28","1367.51","138","173.17","303.52","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.02","59.3","","720.78","230.14","2010.94","427","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","231.02","59.3","","344.45","344.45","344.45","1 through 10","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","305.63","78.45","","1120.13","1120.13","1120.13","1 through 10","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X75MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10037456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.63","78.45","","456.17","105.33","1284.66","242","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","AETNA [1001]","HB CH AETNA HMO / PPO","236.36","58.3","","464.71","67.87","1012.10","221","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","236.36","58.3","","293.04","293.04","293.04","11","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","214.87","53","","983.89","983.89","983.89","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","235.14","58","","677.18","677.18","677.18","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","253.39","62.5","","46.58","46.58","46.58","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","295.96","73","","747.15","747.15","747.15","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.21","44.45","","1141.67","481.21","1141.67","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.21","44.45","","76.54","76.54","76.54","1 through 10","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.42","304.06","WELLPOINT [1015]","HB CH WELLPOINT","315.86","77.91","","273.64","94.28","1367.51","138","180.21","315.86","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.42","304.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.41","59.3","","720.78","230.14","2010.94","427","202.71","318.05","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.42","304.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","240.41","59.3","","344.45","344.45","344.45","1 through 10","202.71","318.05","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.42","304.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","318.05","78.45","","1120.13","1120.13","1120.13","1 through 10","202.71","318.05","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.42","304.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","318.05","78.45","","456.17","105.33","1284.66","242","202.71","318.05","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB CH AETNA HMO / PPO","187.14","58.3","","464.71","67.87","1012.10","221","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","187.14","58.3","","293.04","293.04","293.04","11","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","170.13","53","","983.89","983.89","983.89","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","186.18","58","","677.18","677.18","677.18","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","200.63","62.5","","46.58","46.58","46.58","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","234.33","73","","747.15","747.15","747.15","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.68","44.45","","1141.67","481.21","1141.67","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.68","44.45","","76.54","76.54","76.54","1 through 10","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","WELLPOINT [1015]","HB CH WELLPOINT","250.09","77.91","","273.64","94.28","1367.51","138","142.68","250.09","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","190.35","59.3","","720.78","230.14","2010.94","427","160.5","251.82","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","190.35","59.3","","344.45","344.45","344.45","1 through 10","160.5","251.82","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","251.82","78.45","","1120.13","1120.13","1120.13","1 through 10","160.5","251.82","percent of total billed charges",""
"SCREW BONE 3.5X9MM CORTICAL LOCKING","SUP-ITM-10130596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","251.82","78.45","","456.17","105.33","1284.66","242","160.5","251.82","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","AETNA [1001]","HB CH AETNA HMO / PPO","454.22","58.3","","464.71","67.87","1012.10","221","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.22","58.3","","293.04","293.04","293.04","11","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","412.92","53","","983.89","983.89","983.89","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","451.88","58","","677.18","677.18","677.18","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","486.94","62.5","","46.58","46.58","46.58","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","568.74","73","","747.15","747.15","747.15","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.31","44.45","","1141.67","481.21","1141.67","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.31","44.45","","76.54","76.54","76.54","1 through 10","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","WELLPOINT [1015]","HB CH WELLPOINT","607.00","77.91","","273.64","94.28","1367.51","138","346.31","607","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.01","59.3","","720.78","230.14","2010.94","427","389.55","611.2","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","462.01","59.3","","344.45","344.45","344.45","1 through 10","389.55","611.2","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","611.20","78.45","","1120.13","1120.13","1120.13","1 through 10","389.55","611.2","percent of total billed charges",""
"SCREW BONE 3.6MM L 28 ANCHORAGE T8 LAG CROSS PLATE","SUP-ITM-10174744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.20","78.45","","456.17","105.33","1284.66","242","389.55","611.2","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","464.71","67.87","1012.10","221","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","293.04","293.04","293.04","11","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","983.89","983.89","983.89","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","287.10","58","","677.18","677.18","677.18","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","46.58","46.58","46.58","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","747.15","747.15","747.15","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","1141.67","481.21","1141.67","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","76.54","76.54","76.54","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","273.64","94.28","1367.51","138","220.03","385.65","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","720.78","230.14","2010.94","427","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","293.54","59.3","","344.45","344.45","344.45","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","1120.13","1120.13","1120.13","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","456.17","105.33","1284.66","242","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","AETNA [1001]","HB CH AETNA HMO / PPO","69.79","58.3","","464.71","67.87","1012.10","221","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.79","58.3","","293.04","293.04","293.04","11","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.44","53","","983.89","983.89","983.89","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.43","58","","677.18","677.18","677.18","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","74.81","62.5","","46.58","46.58","46.58","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","747.15","747.15","747.15","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","1141.67","481.21","1141.67","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","76.54","76.54","76.54","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","WELLPOINT [1015]","HB CH WELLPOINT","93.26","77.91","","273.64","94.28","1367.51","138","53.21","93.26","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.98","59.3","","720.78","230.14","2010.94","427","59.85","93.9","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","70.98","59.3","","344.45","344.45","344.45","1 through 10","59.85","93.9","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","1120.13","1120.13","1120.13","1 through 10","59.85","93.9","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","456.17","105.33","1284.66","242","59.85","93.9","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","AETNA [1001]","HB CH AETNA HMO / PPO","211.59","58.3","","464.71","67.87","1012.10","221","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","211.59","58.3","","293.04","293.04","293.04","11","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","192.36","53","","983.89","983.89","983.89","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","210.51","58","","677.18","677.18","677.18","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","226.84","62.5","","46.58","46.58","46.58","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","264.95","73","","747.15","747.15","747.15","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.33","44.45","","1141.67","481.21","1141.67","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.33","44.45","","76.54","76.54","76.54","1 through 10","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.94","272.20","WELLPOINT [1015]","HB CH WELLPOINT","282.77","77.91","","273.64","94.28","1367.51","138","161.33","282.77","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.94","272.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","215.22","59.3","","720.78","230.14","2010.94","427","181.47","284.73","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.94","272.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","215.22","59.3","","344.45","344.45","344.45","1 through 10","181.47","284.73","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.94","272.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","284.73","78.45","","1120.13","1120.13","1120.13","1 through 10","181.47","284.73","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.94","272.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","284.73","78.45","","456.17","105.33","1284.66","242","181.47","284.73","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","AETNA [1001]","HB CH AETNA HMO / PPO","113.69","58.3","","464.71","67.87","1012.10","221","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","113.69","58.3","","293.04","293.04","293.04","11","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","103.35","53","","983.89","983.89","983.89","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","113.10","58","","677.18","677.18","677.18","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","121.88","62.5","","46.58","46.58","46.58","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","142.35","73","","747.15","747.15","747.15","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.68","44.45","","1141.67","481.21","1141.67","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.68","44.45","","76.54","76.54","76.54","1 through 10","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","WELLPOINT [1015]","HB CH WELLPOINT","151.92","77.91","","273.64","94.28","1367.51","138","86.68","151.92","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","115.64","59.3","","720.78","230.14","2010.94","427","97.5","152.98","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","115.64","59.3","","344.45","344.45","344.45","1 through 10","97.5","152.98","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","152.98","78.45","","1120.13","1120.13","1120.13","1 through 10","97.5","152.98","percent of total billed charges",""
"SCREW BONE 32X4.5MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.98","78.45","","456.17","105.33","1284.66","242","97.5","152.98","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","464.71","67.87","1012.10","221","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","293.04","293.04","293.04","11","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","983.89","983.89","983.89","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","104.40","58","","677.18","677.18","677.18","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.50","62.5","","46.58","46.58","46.58","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","747.15","747.15","747.15","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","1141.67","481.21","1141.67","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","76.54","76.54","76.54","1 through 10","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","273.64","94.28","1367.51","138","80.01","140.24","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","720.78","230.14","2010.94","427","90","141.21","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","106.74","59.3","","344.45","344.45","344.45","1 through 10","90","141.21","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","1120.13","1120.13","1120.13","1 through 10","90","141.21","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","456.17","105.33","1284.66","242","90","141.21","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"SCREW BONE 35MM CENTRAL MODULAR","SUP-ITM-10233526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","AETNA [1001]","HB CH AETNA HMO / PPO","166.16","58.3","","464.71","67.87","1012.10","221","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","166.16","58.3","","293.04","293.04","293.04","11","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","151.05","53","","983.89","983.89","983.89","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","165.30","58","","677.18","677.18","677.18","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","178.13","62.5","","46.58","46.58","46.58","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","208.05","73","","747.15","747.15","747.15","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.68","44.45","","1141.67","481.21","1141.67","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.68","44.45","","76.54","76.54","76.54","1 through 10","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","WELLPOINT [1015]","HB CH WELLPOINT","222.04","77.91","","273.64","94.28","1367.51","138","126.68","222.04","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","169.01","59.3","","720.78","230.14","2010.94","427","142.5","223.58","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","169.01","59.3","","344.45","344.45","344.45","1 through 10","142.5","223.58","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","223.58","78.45","","1120.13","1120.13","1120.13","1 through 10","142.5","223.58","percent of total billed charges",""
"SCREW BONE 36X3.5MM ORTHOLOC LOW PROFILE CORTICAL","SUP-ITM-10124567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","223.58","78.45","","456.17","105.33","1284.66","242","142.5","223.58","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","AETNA [1001]","HB CH AETNA HMO / PPO","101.11","58.3","","464.71","67.87","1012.10","221","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","101.11","58.3","","293.04","293.04","293.04","11","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.92","53","","983.89","983.89","983.89","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","100.59","58","","677.18","677.18","677.18","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","108.39","62.5","","46.58","46.58","46.58","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","747.15","747.15","747.15","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","1141.67","481.21","1141.67","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","76.54","76.54","76.54","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","WELLPOINT [1015]","HB CH WELLPOINT","135.12","77.91","","273.64","94.28","1367.51","138","77.09","135.12","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.84","59.3","","720.78","230.14","2010.94","427","86.72","136.06","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.84","59.3","","344.45","344.45","344.45","1 through 10","86.72","136.06","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","1120.13","1120.13","1120.13","1 through 10","86.72","136.06","percent of total billed charges",""
"SCREW BONE 38X4MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","456.17","105.33","1284.66","242","86.72","136.06","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","AETNA [1001]","HB CH AETNA HMO / PPO","298.48","58.3","","464.71","67.87","1012.10","221","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","298.48","58.3","","293.04","293.04","293.04","11","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","271.35","53","","983.89","983.89","983.89","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","296.95","58","","677.18","677.18","677.18","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","319.99","62.5","","46.58","46.58","46.58","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","373.75","73","","747.15","747.15","747.15","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.58","44.45","","1141.67","481.21","1141.67","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.58","44.45","","76.54","76.54","76.54","1 through 10","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.98","383.98","WELLPOINT [1015]","HB CH WELLPOINT","398.88","77.91","","273.64","94.28","1367.51","138","227.58","398.88","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","303.60","59.3","","720.78","230.14","2010.94","427","255.99","401.65","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","303.60","59.3","","344.45","344.45","344.45","1 through 10","255.99","401.65","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","401.65","78.45","","1120.13","1120.13","1120.13","1 through 10","255.99","401.65","percent of total billed charges",""
"SCREW BONE 3MMX18 ANCHORAGE TI NONLOCKING T8 DRIVE","SUP-ITM-10051943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.98","383.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","401.65","78.45","","456.17","105.33","1284.66","242","255.99","401.65","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","AETNA [1001]","HB CH AETNA HMO / PPO","884.99","58.3","","464.71","67.87","1012.10","221","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","884.99","58.3","","293.04","293.04","293.04","11","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.54","53","","983.89","983.89","983.89","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","880.44","58","","677.18","677.18","677.18","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","948.75","62.5","","46.58","46.58","46.58","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","747.15","747.15","747.15","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","1141.67","481.21","1141.67","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","76.54","76.54","76.54","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","WELLPOINT [1015]","HB CH WELLPOINT","1182.67","77.91","","273.64","94.28","1367.51","138","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","900.17","59.3","","720.78","230.14","2010.94","427","759","1190.87","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","900.17","59.3","","344.45","344.45","344.45","1 through 10","759","1190.87","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","1120.13","1120.13","1120.13","1 through 10","759","1190.87","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","456.17","105.33","1284.66","242","759","1190.87","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB CH AETNA HMO / PPO","239.61","58.3","","464.71","67.87","1012.10","221","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","239.61","58.3","","293.04","293.04","293.04","11","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","217.83","53","","983.89","983.89","983.89","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","238.38","58","","677.18","677.18","677.18","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","256.88","62.5","","46.58","46.58","46.58","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","300.03","73","","747.15","747.15","747.15","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.69","44.45","","1141.67","481.21","1141.67","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.69","44.45","","76.54","76.54","76.54","1 through 10","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","WELLPOINT [1015]","HB CH WELLPOINT","320.21","77.91","","273.64","94.28","1367.51","138","182.69","320.21","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","243.72","59.3","","720.78","230.14","2010.94","427","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","243.72","59.3","","344.45","344.45","344.45","1 through 10","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","322.43","78.45","","1120.13","1120.13","1120.13","1 through 10","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM COMPRESSION MULTI THREAD","SUP-ITM-10157789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","322.43","78.45","","456.17","105.33","1284.66","242","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","AETNA [1001]","HB CH AETNA HMO / PPO","594.90","58.3","","464.71","67.87","1012.10","221","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","594.90","58.3","","293.04","293.04","293.04","11","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","540.82","53","","983.89","983.89","983.89","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","591.84","58","","677.18","677.18","677.18","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","637.76","62.5","","46.58","46.58","46.58","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","744.91","73","","747.15","747.15","747.15","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.58","44.45","","1141.67","481.21","1141.67","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.58","44.45","","76.54","76.54","76.54","1 through 10","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","WELLPOINT [1015]","HB CH WELLPOINT","795.01","77.91","","273.64","94.28","1367.51","138","453.58","795.01","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","605.11","59.3","","720.78","230.14","2010.94","427","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","605.11","59.3","","344.45","344.45","344.45","1 through 10","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","800.52","78.45","","1120.13","1120.13","1120.13","1 through 10","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X14.0MM SS CANNULATED COMPRESSION SELF TAPPING","SUP-ITM-10028142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","800.52","78.45","","456.17","105.33","1284.66","242","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","AETNA [1001]","HB CH AETNA HMO / PPO","227.23","58.3","","464.71","67.87","1012.10","221","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.23","58.3","","293.04","293.04","293.04","11","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.57","53","","983.89","983.89","983.89","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","226.06","58","","677.18","677.18","677.18","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","243.60","62.5","","46.58","46.58","46.58","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.52","73","","747.15","747.15","747.15","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.25","44.45","","1141.67","481.21","1141.67","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.25","44.45","","76.54","76.54","76.54","1 through 10","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","WELLPOINT [1015]","HB CH WELLPOINT","303.66","77.91","","273.64","94.28","1367.51","138","173.25","303.66","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.13","59.3","","720.78","230.14","2010.94","427","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","231.13","59.3","","344.45","344.45","344.45","1 through 10","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","305.77","78.45","","1120.13","1120.13","1120.13","1 through 10","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.77","78.45","","456.17","105.33","1284.66","242","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","AETNA [1001]","HB CH AETNA HMO / PPO","431.97","58.3","","464.71","67.87","1012.10","221","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","431.97","58.3","","293.04","293.04","293.04","11","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","392.70","53","","983.89","983.89","983.89","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","429.75","58","","677.18","677.18","677.18","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","463.09","62.5","","46.58","46.58","46.58","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","540.89","73","","747.15","747.15","747.15","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.35","44.45","","1141.67","481.21","1141.67","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.35","44.45","","76.54","76.54","76.54","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","WELLPOINT [1015]","HB CH WELLPOINT","577.27","77.91","","273.64","94.28","1367.51","138","329.35","577.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","439.38","59.3","","720.78","230.14","2010.94","427","370.47","581.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","439.38","59.3","","344.45","344.45","344.45","1 through 10","370.47","581.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","581.27","78.45","","1120.13","1120.13","1120.13","1 through 10","370.47","581.27","percent of total billed charges",""
"SCREW BONE 3X20MM METATARSOPHALANGEAL ANCHORAGE TITANIUM LOCKING T8 DRIVE","SUP-ITM-10051926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","581.27","78.45","","456.17","105.33","1284.66","242","370.47","581.27","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","AETNA [1001]","HB CH AETNA HMO / PPO","364.91","58.3","","464.71","67.87","1012.10","221","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","364.91","58.3","","293.04","293.04","293.04","11","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","331.74","53","","983.89","983.89","983.89","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","363.03","58","","677.18","677.18","677.18","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","391.20","62.5","","46.58","46.58","46.58","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","456.92","73","","747.15","747.15","747.15","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.22","44.45","","1141.67","481.21","1141.67","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.22","44.45","","76.54","76.54","76.54","1 through 10","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","WELLPOINT [1015]","HB CH WELLPOINT","487.65","77.91","","273.64","94.28","1367.51","138","278.22","487.65","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.17","59.3","","720.78","230.14","2010.94","427","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","371.17","59.3","","344.45","344.45","344.45","1 through 10","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","491.03","78.45","","1120.13","1120.13","1120.13","1 through 10","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.03","78.45","","456.17","105.33","1284.66","242","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","AETNA [1001]","HB CH AETNA HMO / PPO","470.90","58.3","","464.71","67.87","1012.10","221","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","470.90","58.3","","293.04","293.04","293.04","11","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.09","53","","983.89","983.89","983.89","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","468.48","58","","677.18","677.18","677.18","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","504.83","62.5","","46.58","46.58","46.58","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","589.64","73","","747.15","747.15","747.15","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.03","44.45","","1141.67","481.21","1141.67","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.03","44.45","","76.54","76.54","76.54","1 through 10","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.72","605.79","WELLPOINT [1015]","HB CH WELLPOINT","629.29","77.91","","273.64","94.28","1367.51","138","359.03","629.29","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.72","605.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","478.98","59.3","","720.78","230.14","2010.94","427","403.86","633.66","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.72","605.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","478.98","59.3","","344.45","344.45","344.45","1 through 10","403.86","633.66","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.72","605.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","633.66","78.45","","1120.13","1120.13","1120.13","1 through 10","403.86","633.66","percent of total billed charges",""
"SCREW BONE 3X30MM MINI HEADED CANNULATED","SUP-ITM-10232463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.72","605.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","633.66","78.45","","456.17","105.33","1284.66","242","403.86","633.66","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","AETNA [1001]","HB CH AETNA HMO / PPO","362.83","58.3","","464.71","67.87","1012.10","221","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","362.83","58.3","","293.04","293.04","293.04","11","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","329.85","53","","983.89","983.89","983.89","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","360.96","58","","677.18","677.18","677.18","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","388.97","62.5","","46.58","46.58","46.58","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","454.32","73","","747.15","747.15","747.15","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","276.63","44.45","","1141.67","481.21","1141.67","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","276.63","44.45","","76.54","76.54","76.54","1 through 10","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","both","","","622.35","466.76","WELLPOINT [1015]","HB CH WELLPOINT","484.87","77.91","","273.64","94.28","1367.51","138","276.63","484.87","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","622.35","466.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","369.05","59.3","","720.78","230.14","2010.94","427","311.18","488.23","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","622.35","466.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","369.05","59.3","","344.45","344.45","344.45","1 through 10","311.18","488.23","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","622.35","466.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","488.23","78.45","","1120.13","1120.13","1120.13","1 through 10","311.18","488.23","percent of total billed charges",""
"SCREW BONE 3X32MM COMPRESSION HEADLESS","SUP-ITM-10230379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","622.35","466.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","488.23","78.45","","456.17","105.33","1284.66","242","311.18","488.23","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","AETNA [1001]","HB CH AETNA HMO / PPO","402.97","58.3","","464.71","67.87","1012.10","221","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","402.97","58.3","","293.04","293.04","293.04","11","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","366.34","53","","983.89","983.89","983.89","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","400.90","58","","677.18","677.18","677.18","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","432.00","62.5","","46.58","46.58","46.58","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","504.58","73","","747.15","747.15","747.15","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.24","44.45","","1141.67","481.21","1141.67","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.24","44.45","","76.54","76.54","76.54","1 through 10","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","WELLPOINT [1015]","HB CH WELLPOINT","538.51","77.91","","273.64","94.28","1367.51","138","307.24","538.51","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","409.88","59.3","","720.78","230.14","2010.94","427","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","409.88","59.3","","344.45","344.45","344.45","1 through 10","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","542.25","78.45","","1120.13","1120.13","1120.13","1 through 10","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X40MM COMPRESSION HEADLESS SHORT THREAD SM JOINT TITANIUM","SUP-ITM-10040422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","542.25","78.45","","456.17","105.33","1284.66","242","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","AETNA [1001]","HB CH AETNA HMO / PPO","210.96","58.3","","464.71","67.87","1012.10","221","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.96","58.3","","293.04","293.04","293.04","11","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.79","53","","983.89","983.89","983.89","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","209.88","58","","677.18","677.18","677.18","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","226.16","62.5","","46.58","46.58","46.58","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","264.16","73","","747.15","747.15","747.15","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.85","44.45","","1141.67","481.21","1141.67","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.85","44.45","","76.54","76.54","76.54","1 through 10","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","WELLPOINT [1015]","HB CH WELLPOINT","281.93","77.91","","273.64","94.28","1367.51","138","160.85","281.93","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.58","59.3","","720.78","230.14","2010.94","427","180.93","283.88","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","214.58","59.3","","344.45","344.45","344.45","1 through 10","180.93","283.88","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","283.88","78.45","","1120.13","1120.13","1120.13","1 through 10","180.93","283.88","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10002366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.88","78.45","","456.17","105.33","1284.66","242","180.93","283.88","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","2190.90","412.50","9264.59","16","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","191.40","58","","1903.20","1903.20","3826.66","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","206.25","62.5","","2186.25","2186.25","2186.25","32","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","5556.60","5556.60","5556.60","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","1955.15","885.83","3150.40","26","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","831.03","253.22","2394.88","18","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","2481.69","1563.74","8149.28","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","2190.90","412.50","9264.59","16","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","156.60","58","","1903.20","1903.20","3826.66","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","2186.25","2186.25","2186.25","32","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","5556.60","5556.60","5556.60","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","1955.15","885.83","3150.40","26","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","831.03","253.22","2394.88","18","135","211.82","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE CERVICAL HYBRID FIXED ANGLE TITANIUM SELF TAPPING ANTERIOR","SUP-ITM-10029673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","2481.69","1563.74","8149.28","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","2190.90","412.50","9264.59","16","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","156.60","58","","1903.20","1903.20","3826.66","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","2186.25","2186.25","2186.25","32","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","5556.60","5556.60","5556.60","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","1955.15","885.83","3150.40","26","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","831.03","253.22","2394.88","18","135","211.82","percent of total billed charges",""
"SCREW BONE 4.0X14MM SPINE SELF DRILL PRIMARY CONSTRAINED CETRA","SUP-ITM-10188544","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","2481.69","1563.74","8149.28","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","464.71","67.87","1012.10","221","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","293.04","293.04","293.04","11","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","983.89","983.89","983.89","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","191.40","58","","677.18","677.18","677.18","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","206.25","62.5","","46.58","46.58","46.58","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","747.15","747.15","747.15","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","1141.67","481.21","1141.67","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","76.54","76.54","76.54","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","273.64","94.28","1367.51","138","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","720.78","230.14","2010.94","427","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","195.69","59.3","","344.45","344.45","344.45","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","1120.13","1120.13","1120.13","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","456.17","105.33","1284.66","242","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","AETNA [1001]","HB CH AETNA HMO / PPO","80.52","58.3","","464.71","67.87","1012.10","221","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","80.52","58.3","","293.04","293.04","293.04","11","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","73.20","53","","983.89","983.89","983.89","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","80.11","58","","677.18","677.18","677.18","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","86.33","62.5","","46.58","46.58","46.58","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","100.83","73","","747.15","747.15","747.15","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.39","44.45","","1141.67","481.21","1141.67","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.39","44.45","","76.54","76.54","76.54","1 through 10","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.12","103.59","WELLPOINT [1015]","HB CH WELLPOINT","107.61","77.91","","273.64","94.28","1367.51","138","61.39","107.61","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.12","103.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.91","59.3","","720.78","230.14","2010.94","427","69.06","108.36","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.12","103.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","81.91","59.3","","344.45","344.45","344.45","1 through 10","69.06","108.36","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.12","103.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","108.36","78.45","","1120.13","1120.13","1120.13","1 through 10","69.06","108.36","percent of total billed charges",""
"SCREW BONE 4.0X18MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10042505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.12","103.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.36","78.45","","456.17","105.33","1284.66","242","69.06","108.36","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","AETNA [1001]","HB CH AETNA HMO / PPO","198.16","58.3","","464.71","67.87","1012.10","221","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.16","58.3","","293.04","293.04","293.04","11","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.15","53","","983.89","983.89","983.89","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","197.14","58","","677.18","677.18","677.18","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","212.44","62.5","","46.58","46.58","46.58","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","747.15","747.15","747.15","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","1141.67","481.21","1141.67","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","76.54","76.54","76.54","1 through 10","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","WELLPOINT [1015]","HB CH WELLPOINT","264.82","77.91","","273.64","94.28","1367.51","138","151.09","264.82","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.56","59.3","","720.78","230.14","2010.94","427","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","201.56","59.3","","344.45","344.45","344.45","1 through 10","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","1120.13","1120.13","1120.13","1 through 10","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","456.17","105.33","1284.66","242","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","AETNA [1001]","HB CH AETNA HMO / PPO","268.42","58.3","","464.71","67.87","1012.10","221","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","268.42","58.3","","293.04","293.04","293.04","11","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.02","53","","983.89","983.89","983.89","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","267.04","58","","677.18","677.18","677.18","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","287.76","62.5","","46.58","46.58","46.58","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","747.15","747.15","747.15","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","1141.67","481.21","1141.67","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","76.54","76.54","76.54","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","WELLPOINT [1015]","HB CH WELLPOINT","358.71","77.91","","273.64","94.28","1367.51","138","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","273.02","59.3","","720.78","230.14","2010.94","427","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","273.02","59.3","","344.45","344.45","344.45","1 through 10","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","1120.13","1120.13","1120.13","1 through 10","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","456.17","105.33","1284.66","242","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","AETNA [1001]","HB CH AETNA HMO / PPO","195.89","58.3","","464.71","67.87","1012.10","221","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","195.89","58.3","","293.04","293.04","293.04","11","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","178.08","53","","983.89","983.89","983.89","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","194.88","58","","677.18","677.18","677.18","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","210.00","62.5","","46.58","46.58","46.58","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","245.28","73","","747.15","747.15","747.15","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.35","44.45","","1141.67","481.21","1141.67","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.35","44.45","","76.54","76.54","76.54","1 through 10","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","WELLPOINT [1015]","HB CH WELLPOINT","261.78","77.91","","273.64","94.28","1367.51","138","149.35","261.78","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","199.25","59.3","","720.78","230.14","2010.94","427","168","263.59","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","199.25","59.3","","344.45","344.45","344.45","1 through 10","168","263.59","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","263.59","78.45","","1120.13","1120.13","1120.13","1 through 10","168","263.59","percent of total billed charges",""
"SCREW BONE 4.0X44MM CANCELLOUS TITANIUM LOCKING","SUP-ITM-10139189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","263.59","78.45","","456.17","105.33","1284.66","242","168","263.59","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","AETNA [1001]","HB CH AETNA HMO / PPO","268.42","58.3","","464.71","67.87","1012.10","221","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","268.42","58.3","","293.04","293.04","293.04","11","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.02","53","","983.89","983.89","983.89","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","267.04","58","","677.18","677.18","677.18","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","287.76","62.5","","46.58","46.58","46.58","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","747.15","747.15","747.15","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","1141.67","481.21","1141.67","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","76.54","76.54","76.54","1 through 10","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","WELLPOINT [1015]","HB CH WELLPOINT","358.71","77.91","","273.64","94.28","1367.51","138","204.65","358.71","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","273.02","59.3","","720.78","230.14","2010.94","427","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","273.02","59.3","","344.45","344.45","344.45","1 through 10","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","1120.13","1120.13","1120.13","1 through 10","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","456.17","105.33","1284.66","242","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","AETNA [1001]","HB CH AETNA HMO / PPO","61.25","58.3","","464.71","67.87","1012.10","221","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.25","58.3","","293.04","293.04","293.04","11","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.68","53","","983.89","983.89","983.89","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","60.93","58","","677.18","677.18","677.18","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.66","62.5","","46.58","46.58","46.58","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","747.15","747.15","747.15","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","1141.67","481.21","1141.67","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","76.54","76.54","76.54","1 through 10","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","WELLPOINT [1015]","HB CH WELLPOINT","81.85","77.91","","273.64","94.28","1367.51","138","46.7","81.85","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.30","59.3","","720.78","230.14","2010.94","427","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.30","59.3","","344.45","344.45","344.45","1 through 10","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","1120.13","1120.13","1120.13","1 through 10","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","456.17","105.33","1284.66","242","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","AETNA [1001]","HB CH AETNA HMO / PPO","447.52","58.3","","464.71","67.87","1012.10","221","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","447.52","58.3","","293.04","293.04","293.04","11","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","406.83","53","","983.89","983.89","983.89","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","445.21","58","","677.18","677.18","677.18","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","479.76","62.5","","46.58","46.58","46.58","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","560.36","73","","747.15","747.15","747.15","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.20","44.45","","1141.67","481.21","1141.67","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.20","44.45","","76.54","76.54","76.54","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","WELLPOINT [1015]","HB CH WELLPOINT","598.04","77.91","","273.64","94.28","1367.51","138","341.2","598.04","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","455.19","59.3","","720.78","230.14","2010.94","427","383.81","602.19","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","455.19","59.3","","344.45","344.45","344.45","1 through 10","383.81","602.19","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","602.19","78.45","","1120.13","1120.13","1120.13","1 through 10","383.81","602.19","percent of total billed charges",""
"SCREW BONE 4.0X70MM AXSOS TITANIUM LOCKING","SUP-ITM-10144930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","602.19","78.45","","456.17","105.33","1284.66","242","383.81","602.19","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","464.71","67.87","1012.10","221","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","293.04","293.04","293.04","11","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","983.89","983.89","983.89","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","269.70","58","","677.18","677.18","677.18","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","290.63","62.5","","46.58","46.58","46.58","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","747.15","747.15","747.15","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","1141.67","481.21","1141.67","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","76.54","76.54","76.54","1 through 10","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","273.64","94.28","1367.51","138","206.69","362.28","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","720.78","230.14","2010.94","427","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","275.75","59.3","","344.45","344.45","344.45","1 through 10","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","1120.13","1120.13","1120.13","1 through 10","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.2X46MM R3CON NONLOCKING PLATE","SUP-ITM-10237577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","456.17","105.33","1284.66","242","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","AETNA [1001]","HB CH AETNA HMO / PPO","884.99","58.3","","464.71","67.87","1012.10","221","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","884.99","58.3","","293.04","293.04","293.04","11","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.54","53","","983.89","983.89","983.89","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","880.44","58","","677.18","677.18","677.18","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","948.75","62.5","","46.58","46.58","46.58","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","747.15","747.15","747.15","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","1141.67","481.21","1141.67","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","76.54","76.54","76.54","1 through 10","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","WELLPOINT [1015]","HB CH WELLPOINT","1182.67","77.91","","273.64","94.28","1367.51","138","674.75","1182.67","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","900.17","59.3","","720.78","230.14","2010.94","427","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","900.17","59.3","","344.45","344.45","344.45","1 through 10","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","1120.13","1120.13","1120.13","1 through 10","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","456.17","105.33","1284.66","242","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB CH AETNA HMO / PPO","306.08","58.3","","464.71","67.87","1012.10","221","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","306.08","58.3","","293.04","293.04","293.04","11","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","278.25","53","","983.89","983.89","983.89","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","304.50","58","","677.18","677.18","677.18","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","328.13","62.5","","46.58","46.58","46.58","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","383.25","73","","747.15","747.15","747.15","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.36","44.45","","1141.67","481.21","1141.67","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.36","44.45","","76.54","76.54","76.54","1 through 10","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB CH WELLPOINT","409.03","77.91","","273.64","94.28","1367.51","138","233.36","409.03","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.33","59.3","","720.78","230.14","2010.94","427","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","311.33","59.3","","344.45","344.45","344.45","1 through 10","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","411.86","78.45","","1120.13","1120.13","1120.13","1 through 10","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","411.86","78.45","","456.17","105.33","1284.66","242","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","464.71","67.87","1012.10","221","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","157.41","58.3","","293.04","293.04","293.04","11","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","983.89","983.89","983.89","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","156.60","58","","677.18","677.18","677.18","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","46.58","46.58","46.58","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","747.15","747.15","747.15","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","1141.67","481.21","1141.67","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","76.54","76.54","76.54","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","273.64","94.28","1367.51","138","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","720.78","230.14","2010.94","427","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","160.11","59.3","","344.45","344.45","344.45","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","1120.13","1120.13","1120.13","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X14MM SPINE CERVICAL HALLMARK TITANIUM PRIMARY CONSTRAINED VARIABLE ANGLE SELF TAPPING","SUP-ITM-10109937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","456.17","105.33","1284.66","242","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","464.71","67.87","1012.10","221","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","157.41","58.3","","293.04","293.04","293.04","11","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","983.89","983.89","983.89","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","156.60","58","","677.18","677.18","677.18","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","46.58","46.58","46.58","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","747.15","747.15","747.15","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","1141.67","481.21","1141.67","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","76.54","76.54","76.54","1 through 10","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","273.64","94.28","1367.51","138","120.02","210.36","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","720.78","230.14","2010.94","427","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","160.11","59.3","","344.45","344.45","344.45","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","1120.13","1120.13","1120.13","1 through 10","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X15MM SPINE ARCHON SELF TAPPING VARIABLE","SUP-ITM-10171673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","456.17","105.33","1284.66","242","135","211.82","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","AETNA [1001]","HB CH AETNA HMO / PPO","713.59","58.3","","464.71","67.87","1012.10","221","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","713.59","58.3","","293.04","293.04","293.04","11","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","648.72","53","","983.89","983.89","983.89","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","709.92","58","","677.18","677.18","677.18","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","765.00","62.5","","46.58","46.58","46.58","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","893.52","73","","747.15","747.15","747.15","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","544.07","44.45","","1141.67","481.21","1141.67","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","544.07","44.45","","76.54","76.54","76.54","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","WELLPOINT [1015]","HB CH WELLPOINT","953.62","77.91","","273.64","94.28","1367.51","138","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","725.83","59.3","","720.78","230.14","2010.94","427","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","725.83","59.3","","344.45","344.45","344.45","1 through 10","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","960.23","78.45","","1120.13","1120.13","1120.13","1 through 10","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI CANNULATED","SUP-ITM-10270230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","960.23","78.45","","456.17","105.33","1284.66","242","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","464.71","67.87","1012.10","221","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","293.04","293.04","293.04","11","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","983.89","983.89","983.89","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","607.26","58","","677.18","677.18","677.18","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","654.38","62.5","","46.58","46.58","46.58","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","747.15","747.15","747.15","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","1141.67","481.21","1141.67","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","76.54","76.54","76.54","1 through 10","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","273.64","94.28","1367.51","138","465.39","815.72","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","720.78","230.14","2010.94","427","523.5","821.37","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","620.87","59.3","","344.45","344.45","344.45","1 through 10","523.5","821.37","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","1120.13","1120.13","1120.13","1 through 10","523.5","821.37","percent of total billed charges",""
"SCREW BONE 4.5X16MM TI SOLID","SUP-ITM-10270235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","456.17","105.33","1284.66","242","523.5","821.37","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","AETNA [1001]","HB CH AETNA HMO / PPO","108.02","58.3","","464.71","67.87","1012.10","221","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.02","58.3","","293.04","293.04","293.04","11","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.20","53","","983.89","983.89","983.89","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","107.46","58","","677.18","677.18","677.18","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","115.80","62.5","","46.58","46.58","46.58","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","747.15","747.15","747.15","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","1141.67","481.21","1141.67","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","76.54","76.54","76.54","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","WELLPOINT [1015]","HB CH WELLPOINT","144.35","77.91","","273.64","94.28","1367.51","138","82.36","144.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.87","59.3","","720.78","230.14","2010.94","427","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","109.87","59.3","","344.45","344.45","344.45","1 through 10","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","1120.13","1120.13","1120.13","1 through 10","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","456.17","105.33","1284.66","242","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","AETNA [1001]","HB CH AETNA HMO / PPO","224.99","58.3","","464.71","67.87","1012.10","221","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","224.99","58.3","","293.04","293.04","293.04","11","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","204.54","53","","983.89","983.89","983.89","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","223.83","58","","677.18","677.18","677.18","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","241.20","62.5","","46.58","46.58","46.58","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","747.15","747.15","747.15","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","1141.67","481.21","1141.67","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","76.54","76.54","76.54","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","WELLPOINT [1015]","HB CH WELLPOINT","300.67","77.91","","273.64","94.28","1367.51","138","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","228.85","59.3","","720.78","230.14","2010.94","427","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","228.85","59.3","","344.45","344.45","344.45","1 through 10","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","1120.13","1120.13","1120.13","1 through 10","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","456.17","105.33","1284.66","242","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","AETNA [1001]","HB CH AETNA HMO / PPO","537.40","58.3","","464.71","67.87","1012.10","221","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","537.40","58.3","","293.04","293.04","293.04","11","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","488.54","53","","983.89","983.89","983.89","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","534.63","58","","677.18","677.18","677.18","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","576.11","62.5","","46.58","46.58","46.58","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","672.90","73","","747.15","747.15","747.15","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.73","44.45","","1141.67","481.21","1141.67","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.73","44.45","","76.54","76.54","76.54","1 through 10","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","WELLPOINT [1015]","HB CH WELLPOINT","718.16","77.91","","273.64","94.28","1367.51","138","409.73","718.16","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","546.62","59.3","","720.78","230.14","2010.94","427","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","546.62","59.3","","344.45","344.45","344.45","1 through 10","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","723.14","78.45","","1120.13","1120.13","1120.13","1 through 10","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","723.14","78.45","","456.17","105.33","1284.66","242","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","464.71","67.87","1012.10","221","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","293.04","293.04","293.04","11","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","983.89","983.89","983.89","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","677.18","677.18","677.18","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","46.58","46.58","46.58","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","747.15","747.15","747.15","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","1141.67","481.21","1141.67","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","76.54","76.54","76.54","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","273.64","94.28","1367.51","138","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","720.78","230.14","2010.94","427","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","135.20","59.3","","344.45","344.45","344.45","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","1120.13","1120.13","1120.13","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","456.17","105.33","1284.66","242","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","464.71","67.87","1012.10","221","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","293.04","293.04","293.04","11","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","983.89","983.89","983.89","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","677.18","677.18","677.18","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","46.58","46.58","46.58","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","747.15","747.15","747.15","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","1141.67","481.21","1141.67","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","76.54","76.54","76.54","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","273.64","94.28","1367.51","138","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","720.78","230.14","2010.94","427","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","135.20","59.3","","344.45","344.45","344.45","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","1120.13","1120.13","1120.13","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","456.17","105.33","1284.66","242","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","AETNA [1001]","HB CH AETNA HMO / PPO","713.59","58.3","","464.71","67.87","1012.10","221","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","713.59","58.3","","293.04","293.04","293.04","11","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","648.72","53","","983.89","983.89","983.89","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","709.92","58","","677.18","677.18","677.18","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","765.00","62.5","","46.58","46.58","46.58","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","893.52","73","","747.15","747.15","747.15","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","544.07","44.45","","1141.67","481.21","1141.67","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","544.07","44.45","","76.54","76.54","76.54","1 through 10","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1224.00","918.00","WELLPOINT [1015]","HB CH WELLPOINT","953.62","77.91","","273.64","94.28","1367.51","138","544.07","953.62","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","725.83","59.3","","720.78","230.14","2010.94","427","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","725.83","59.3","","344.45","344.45","344.45","1 through 10","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","960.23","78.45","","1120.13","1120.13","1120.13","1 through 10","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X24MM TI CANNULATED","SUP-ITM-10270231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1224.00","918.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","960.23","78.45","","456.17","105.33","1284.66","242","612","960.23","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","464.71","67.87","1012.10","221","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","293.04","293.04","293.04","11","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","983.89","983.89","983.89","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","136.85","58","","677.18","677.18","677.18","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","147.47","62.5","","46.58","46.58","46.58","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","747.15","747.15","747.15","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","1141.67","481.21","1141.67","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","76.54","76.54","76.54","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","273.64","94.28","1367.51","138","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","720.78","230.14","2010.94","427","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","139.92","59.3","","344.45","344.45","344.45","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","1120.13","1120.13","1120.13","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","456.17","105.33","1284.66","242","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","464.71","67.87","1012.10","221","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","293.04","293.04","293.04","11","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","983.89","983.89","983.89","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","136.85","58","","677.18","677.18","677.18","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","147.47","62.5","","46.58","46.58","46.58","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","747.15","747.15","747.15","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","1141.67","481.21","1141.67","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","76.54","76.54","76.54","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","273.64","94.28","1367.51","138","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","720.78","230.14","2010.94","427","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","139.92","59.3","","344.45","344.45","344.45","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","1120.13","1120.13","1120.13","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","456.17","105.33","1284.66","242","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","464.71","67.87","1012.10","221","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","293.04","293.04","293.04","11","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","983.89","983.89","983.89","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","677.18","677.18","677.18","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","46.58","46.58","46.58","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","747.15","747.15","747.15","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","1141.67","481.21","1141.67","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","76.54","76.54","76.54","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","273.64","94.28","1367.51","138","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","720.78","230.14","2010.94","427","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","135.20","59.3","","344.45","344.45","344.45","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","1120.13","1120.13","1120.13","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","456.17","105.33","1284.66","242","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","464.71","67.87","1012.10","221","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","293.04","293.04","293.04","11","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","983.89","983.89","983.89","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","677.18","677.18","677.18","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","46.58","46.58","46.58","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","747.15","747.15","747.15","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","1141.67","481.21","1141.67","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","76.54","76.54","76.54","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","273.64","94.28","1367.51","138","101.35","177.63","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","720.78","230.14","2010.94","427","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","135.20","59.3","","344.45","344.45","344.45","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","1120.13","1120.13","1120.13","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","456.17","105.33","1284.66","242","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","AETNA [1001]","HB CH AETNA HMO / PPO","224.99","58.3","","464.71","67.87","1012.10","221","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","224.99","58.3","","293.04","293.04","293.04","11","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","204.54","53","","983.89","983.89","983.89","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","223.83","58","","677.18","677.18","677.18","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","241.20","62.5","","46.58","46.58","46.58","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","747.15","747.15","747.15","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","1141.67","481.21","1141.67","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","76.54","76.54","76.54","1 through 10","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","WELLPOINT [1015]","HB CH WELLPOINT","300.67","77.91","","273.64","94.28","1367.51","138","171.54","300.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","228.85","59.3","","720.78","230.14","2010.94","427","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","228.85","59.3","","344.45","344.45","344.45","1 through 10","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","1120.13","1120.13","1120.13","1 through 10","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","456.17","105.33","1284.66","242","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","AETNA [1001]","HB CH AETNA HMO / PPO","372.54","58.3","","464.71","67.87","1012.10","221","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","372.54","58.3","","293.04","293.04","293.04","11","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","338.67","53","","983.89","983.89","983.89","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","370.62","58","","677.18","677.18","677.18","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","399.38","62.5","","46.58","46.58","46.58","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","466.47","73","","747.15","747.15","747.15","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.04","44.45","","1141.67","481.21","1141.67","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.04","44.45","","76.54","76.54","76.54","1 through 10","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.00","479.25","WELLPOINT [1015]","HB CH WELLPOINT","497.84","77.91","","273.64","94.28","1367.51","138","284.04","497.84","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.00","479.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","378.93","59.3","","720.78","230.14","2010.94","427","319.5","501.3","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.00","479.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","378.93","59.3","","344.45","344.45","344.45","1 through 10","319.5","501.3","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.00","479.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","501.30","78.45","","1120.13","1120.13","1120.13","1 through 10","319.5","501.3","percent of total billed charges",""
"SCREW BONE 4.5X32MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.00","479.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","501.30","78.45","","456.17","105.33","1284.66","242","319.5","501.3","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","464.71","67.87","1012.10","221","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","857.01","58.3","","293.04","293.04","293.04","11","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.10","53","","983.89","983.89","983.89","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","852.60","58","","677.18","677.18","677.18","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","918.75","62.5","","46.58","46.58","46.58","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","747.15","747.15","747.15","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","1141.67","481.21","1141.67","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","76.54","76.54","76.54","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","273.64","94.28","1367.51","138","653.42","1145.28","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","720.78","230.14","2010.94","427","735","1153.22","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","871.71","59.3","","344.45","344.45","344.45","1 through 10","735","1153.22","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","1120.13","1120.13","1120.13","1 through 10","735","1153.22","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE FIREBIRD MULTIAXIAL TITANIUM SELF TAPPING","SUP-ITM-10083317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","456.17","105.33","1284.66","242","735","1153.22","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","AETNA [1001]","HB CH AETNA HMO / PPO","87.36","58.3","","464.71","67.87","1012.10","221","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.36","58.3","","293.04","293.04","293.04","11","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.42","53","","983.89","983.89","983.89","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","86.91","58","","677.18","677.18","677.18","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.66","62.5","","46.58","46.58","46.58","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.39","73","","747.15","747.15","747.15","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.61","44.45","","1141.67","481.21","1141.67","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.61","44.45","","76.54","76.54","76.54","1 through 10","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","WELLPOINT [1015]","HB CH WELLPOINT","116.75","77.91","","273.64","94.28","1367.51","138","66.61","116.75","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.86","59.3","","720.78","230.14","2010.94","427","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.86","59.3","","344.45","344.45","344.45","1 through 10","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.56","78.45","","1120.13","1120.13","1120.13","1 through 10","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.56","78.45","","456.17","105.33","1284.66","242","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","464.71","67.87","1012.10","221","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","293.04","293.04","293.04","11","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","983.89","983.89","983.89","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","136.85","58","","677.18","677.18","677.18","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","147.47","62.5","","46.58","46.58","46.58","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","747.15","747.15","747.15","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","1141.67","481.21","1141.67","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","76.54","76.54","76.54","1 through 10","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","273.64","94.28","1367.51","138","104.88","183.83","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","720.78","230.14","2010.94","427","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","139.92","59.3","","344.45","344.45","344.45","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","1120.13","1120.13","1120.13","1 through 10","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X36MM LOCK UNIV REV UNIVERSAL REVERSE PERIPHERAL","SUP-ITM-10148148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","456.17","105.33","1284.66","242","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","AETNA [1001]","HB CH AETNA HMO / PPO","231.15","58.3","","464.71","67.87","1012.10","221","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","231.15","58.3","","293.04","293.04","293.04","11","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","210.13","53","","983.89","983.89","983.89","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","229.96","58","","677.18","677.18","677.18","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","247.80","62.5","","46.58","46.58","46.58","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","289.43","73","","747.15","747.15","747.15","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.24","44.45","","1141.67","481.21","1141.67","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.24","44.45","","76.54","76.54","76.54","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","WELLPOINT [1015]","HB CH WELLPOINT","308.90","77.91","","273.64","94.28","1367.51","138","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","235.11","59.3","","720.78","230.14","2010.94","427","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","235.11","59.3","","344.45","344.45","344.45","1 through 10","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","311.04","78.45","","1120.13","1120.13","1120.13","1 through 10","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","311.04","78.45","","456.17","105.33","1284.66","242","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","AETNA [1001]","HB CH AETNA HMO / PPO","323.57","58.3","","464.71","67.87","1012.10","221","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","323.57","58.3","","293.04","293.04","293.04","11","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.15","53","","983.89","983.89","983.89","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","321.90","58","","677.18","677.18","677.18","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","346.88","62.5","","46.58","46.58","46.58","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.15","73","","747.15","747.15","747.15","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.70","44.45","","1141.67","481.21","1141.67","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.70","44.45","","76.54","76.54","76.54","1 through 10","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","WELLPOINT [1015]","HB CH WELLPOINT","432.40","77.91","","273.64","94.28","1367.51","138","246.7","432.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.12","59.3","","720.78","230.14","2010.94","427","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","329.12","59.3","","344.45","344.45","344.45","1 through 10","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","1120.13","1120.13","1120.13","1 through 10","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X44MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","456.17","105.33","1284.66","242","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","464.71","67.87","1012.10","221","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","293.04","293.04","293.04","11","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","983.89","983.89","983.89","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1653.00","58","","677.18","677.18","677.18","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1781.25","62.5","","46.58","46.58","46.58","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","747.15","747.15","747.15","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","1141.67","481.21","1141.67","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","76.54","76.54","76.54","1 through 10","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","273.64","94.28","1367.51","138","1266.83","2220.44","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","720.78","230.14","2010.94","427","1425","2235.83","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1690.05","59.3","","344.45","344.45","344.45","1 through 10","1425","2235.83","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","1120.13","1120.13","1120.13","1 through 10","1425","2235.83","percent of total billed charges",""
"SCREW BONE 4.5X45MM CHAMFERED","SUP-ITM-10239348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","456.17","105.33","1284.66","242","1425","2235.83","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","AETNA [1001]","HB CH AETNA HMO / PPO","47.24","58.3","","464.71","67.87","1012.10","221","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.24","58.3","","293.04","293.04","293.04","11","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.95","53","","983.89","983.89","983.89","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","47.00","58","","677.18","677.18","677.18","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","50.64","62.5","","46.58","46.58","46.58","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.15","73","","747.15","747.15","747.15","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.02","44.45","","1141.67","481.21","1141.67","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.02","44.45","","76.54","76.54","76.54","1 through 10","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","WELLPOINT [1015]","HB CH WELLPOINT","63.13","77.91","","273.64","94.28","1367.51","138","36.02","63.13","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.05","59.3","","720.78","230.14","2010.94","427","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","48.05","59.3","","344.45","344.45","344.45","1 through 10","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.57","78.45","","1120.13","1120.13","1120.13","1 through 10","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.57","78.45","","456.17","105.33","1284.66","242","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","AETNA [1001]","HB CH AETNA HMO / PPO","106.72","58.3","","464.71","67.87","1012.10","221","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.72","58.3","","293.04","293.04","293.04","11","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.02","53","","983.89","983.89","983.89","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","106.17","58","","677.18","677.18","677.18","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","114.41","62.5","","46.58","46.58","46.58","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","747.15","747.15","747.15","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","1141.67","481.21","1141.67","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","76.54","76.54","76.54","1 through 10","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","WELLPOINT [1015]","HB CH WELLPOINT","142.62","77.91","","273.64","94.28","1367.51","138","81.37","142.62","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.55","59.3","","720.78","230.14","2010.94","427","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","108.55","59.3","","344.45","344.45","344.45","1 through 10","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","1120.13","1120.13","1120.13","1 through 10","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10139454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","456.17","105.33","1284.66","242","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","AETNA [1001]","HB CH AETNA HMO / PPO","97.37","58.3","","464.71","67.87","1012.10","221","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.37","58.3","","293.04","293.04","293.04","11","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.52","53","","983.89","983.89","983.89","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","96.87","58","","677.18","677.18","677.18","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","104.38","62.5","","46.58","46.58","46.58","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","121.92","73","","747.15","747.15","747.15","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.24","44.45","","1141.67","481.21","1141.67","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.24","44.45","","76.54","76.54","76.54","1 through 10","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","WELLPOINT [1015]","HB CH WELLPOINT","130.12","77.91","","273.64","94.28","1367.51","138","74.24","130.12","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.04","59.3","","720.78","230.14","2010.94","427","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","99.04","59.3","","344.45","344.45","344.45","1 through 10","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","131.02","78.45","","1120.13","1120.13","1120.13","1 through 10","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.02","78.45","","456.17","105.33","1284.66","242","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","AETNA [1001]","HB CH AETNA HMO / PPO","231.15","58.3","","464.71","67.87","1012.10","221","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","231.15","58.3","","293.04","293.04","293.04","11","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","210.13","53","","983.89","983.89","983.89","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","229.96","58","","677.18","677.18","677.18","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","247.80","62.5","","46.58","46.58","46.58","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","289.43","73","","747.15","747.15","747.15","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.24","44.45","","1141.67","481.21","1141.67","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.24","44.45","","76.54","76.54","76.54","1 through 10","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","WELLPOINT [1015]","HB CH WELLPOINT","308.90","77.91","","273.64","94.28","1367.51","138","176.24","308.9","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","235.11","59.3","","720.78","230.14","2010.94","427","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","235.11","59.3","","344.45","344.45","344.45","1 through 10","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","311.04","78.45","","1120.13","1120.13","1120.13","1 through 10","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X76MM CANNULATED FULLY THREADED LG HEX HEAD SS","SUP-ITM-10037494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","311.04","78.45","","456.17","105.33","1284.66","242","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","AETNA [1001]","HB CH AETNA HMO / PPO","83.48","58.3","","464.71","67.87","1012.10","221","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","83.48","58.3","","293.04","293.04","293.04","11","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.89","53","","983.89","983.89","983.89","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","83.05","58","","677.18","677.18","677.18","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","89.49","62.5","","46.58","46.58","46.58","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","104.53","73","","747.15","747.15","747.15","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.65","44.45","","1141.67","481.21","1141.67","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.65","44.45","","76.54","76.54","76.54","1 through 10","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.19","107.39","WELLPOINT [1015]","HB CH WELLPOINT","111.56","77.91","","273.64","94.28","1367.51","138","63.65","111.56","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.19","107.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.91","59.3","","720.78","230.14","2010.94","427","71.6","112.33","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","84.91","59.3","","344.45","344.45","344.45","1 through 10","71.6","112.33","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","112.33","78.45","","1120.13","1120.13","1120.13","1 through 10","71.6","112.33","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.19","107.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.33","78.45","","456.17","105.33","1284.66","242","71.6","112.33","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","AETNA [1001]","HB CH AETNA HMO / PPO","668.12","58.3","","464.71","67.87","1012.10","221","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","668.12","58.3","","293.04","293.04","293.04","11","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","607.38","53","","983.89","983.89","983.89","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","664.68","58","","677.18","677.18","677.18","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","716.25","62.5","","46.58","46.58","46.58","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","836.58","73","","747.15","747.15","747.15","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","509.40","44.45","","1141.67","481.21","1141.67","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","509.40","44.45","","76.54","76.54","76.54","1 through 10","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","both","","","1146.00","859.50","WELLPOINT [1015]","HB CH WELLPOINT","892.85","77.91","","273.64","94.28","1367.51","138","509.4","892.85","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.00","859.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","679.58","59.3","","720.78","230.14","2010.94","427","573","899.04","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.00","859.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","679.58","59.3","","344.45","344.45","344.45","1 through 10","573","899.04","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.00","859.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","899.04","78.45","","1120.13","1120.13","1120.13","1 through 10","573","899.04","percent of total billed charges",""
"SCREW BONE 40MMX8 3 SELF DRILLING CANNULATED COMPRESSION HEXAGONAL DRIVE 10 APTUS TITANIUM IMPLANTABLE","SUP-ITM-10114354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1146.00","859.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","899.04","78.45","","456.17","105.33","1284.66","242","573","899.04","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","464.71","67.87","1012.10","221","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","293.04","293.04","293.04","11","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","983.89","983.89","983.89","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","677.18","677.18","677.18","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","46.58","46.58","46.58","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","747.15","747.15","747.15","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","1141.67","481.21","1141.67","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","76.54","76.54","76.54","1 through 10","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","273.64","94.28","1367.51","138","200.03","350.6","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","720.78","230.14","2010.94","427","225","353.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","266.85","59.3","","344.45","344.45","344.45","1 through 10","225","353.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1120.13","1120.13","1120.13","1 through 10","225","353.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","456.17","105.33","1284.66","242","225","353.03","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","464.71","67.87","1012.10","221","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","682.11","58.3","","293.04","293.04","293.04","11","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","620.10","53","","983.89","983.89","983.89","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","678.60","58","","677.18","677.18","677.18","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","731.25","62.5","","46.58","46.58","46.58","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","747.15","747.15","747.15","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","1141.67","481.21","1141.67","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","76.54","76.54","76.54","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","273.64","94.28","1367.51","138","520.07","911.55","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","720.78","230.14","2010.94","427","585","917.87","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","693.81","59.3","","344.45","344.45","344.45","1 through 10","585","917.87","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","1120.13","1120.13","1120.13","1 through 10","585","917.87","percent of total billed charges",""
"SCREW BONE 40X6.5MM SPINE FIXATION FIREBIRD CANNULATED DOUBLE LEAD SELF TAPPING","SUP-ITM-10083579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","456.17","105.33","1284.66","242","585","917.87","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","AETNA [1001]","HB CH AETNA HMO / PPO","402.27","58.3","","464.71","67.87","1012.10","221","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","402.27","58.3","","293.04","293.04","293.04","11","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","365.70","53","","983.89","983.89","983.89","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","400.20","58","","677.18","677.18","677.18","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","431.25","62.5","","46.58","46.58","46.58","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","503.70","73","","747.15","747.15","747.15","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.71","44.45","","1141.67","481.21","1141.67","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.71","44.45","","76.54","76.54","76.54","1 through 10","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.00","517.50","WELLPOINT [1015]","HB CH WELLPOINT","537.58","77.91","","273.64","94.28","1367.51","138","306.71","537.58","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.00","517.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","409.17","59.3","","720.78","230.14","2010.94","427","345","541.31","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.00","517.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","409.17","59.3","","344.45","344.45","344.45","1 through 10","345","541.31","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.00","517.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","541.31","78.45","","1120.13","1120.13","1120.13","1 through 10","345","541.31","percent of total billed charges",""
"SCREW BONE 42X4.3MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10056925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.00","517.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","541.31","78.45","","456.17","105.33","1284.66","242","345","541.31","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","464.71","67.87","1012.10","221","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","293.04","293.04","293.04","11","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","983.89","983.89","983.89","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","60.90","58","","677.18","677.18","677.18","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.63","62.5","","46.58","46.58","46.58","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","747.15","747.15","747.15","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","1141.67","481.21","1141.67","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","76.54","76.54","76.54","1 through 10","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","273.64","94.28","1367.51","138","46.67","81.81","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","720.78","230.14","2010.94","427","52.5","82.37","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.27","59.3","","344.45","344.45","344.45","1 through 10","52.5","82.37","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","1120.13","1120.13","1120.13","1 through 10","52.5","82.37","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","456.17","105.33","1284.66","242","52.5","82.37","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","AETNA [1001]","HB CH AETNA HMO / PPO","556.13","58.3","","464.71","67.87","1012.10","221","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","556.13","58.3","","293.04","293.04","293.04","11","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.57","53","","983.89","983.89","983.89","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","553.27","58","","677.18","677.18","677.18","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","596.19","62.5","","46.58","46.58","46.58","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","696.35","73","","747.15","747.15","747.15","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.01","44.45","","1141.67","481.21","1141.67","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.01","44.45","","76.54","76.54","76.54","1 through 10","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","both","","","953.91","715.43","WELLPOINT [1015]","HB CH WELLPOINT","743.19","77.91","","273.64","94.28","1367.51","138","424.01","743.19","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","953.91","715.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","565.67","59.3","","720.78","230.14","2010.94","427","476.96","748.34","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","565.67","59.3","","344.45","344.45","344.45","1 through 10","476.96","748.34","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","748.34","78.45","","1120.13","1120.13","1120.13","1 through 10","476.96","748.34","percent of total billed charges",""
"SCREW BONE 45X5MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","953.91","715.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.34","78.45","","456.17","105.33","1284.66","242","476.96","748.34","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","AETNA [1001]","HB CH AETNA HMO / PPO","99.17","58.3","","464.71","67.87","1012.10","221","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.17","58.3","","293.04","293.04","293.04","11","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.15","53","","983.89","983.89","983.89","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","98.66","58","","677.18","677.18","677.18","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","106.31","62.5","","46.58","46.58","46.58","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.17","73","","747.15","747.15","747.15","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.61","44.45","","1141.67","481.21","1141.67","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.61","44.45","","76.54","76.54","76.54","1 through 10","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","WELLPOINT [1015]","HB CH WELLPOINT","132.52","77.91","","273.64","94.28","1367.51","138","75.61","132.52","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.87","59.3","","720.78","230.14","2010.94","427","85.05","133.44","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","100.87","59.3","","344.45","344.45","344.45","1 through 10","85.05","133.44","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","133.44","78.45","","1120.13","1120.13","1120.13","1 through 10","85.05","133.44","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.44","78.45","","456.17","105.33","1284.66","242","85.05","133.44","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","AETNA [1001]","HB CH AETNA HMO / PPO","444.95","58.3","","464.71","67.87","1012.10","221","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","444.95","58.3","","293.04","293.04","293.04","11","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.50","53","","983.89","983.89","983.89","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","442.66","58","","677.18","677.18","677.18","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","477.00","62.5","","46.58","46.58","46.58","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","557.14","73","","747.15","747.15","747.15","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.24","44.45","","1141.67","481.21","1141.67","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.24","44.45","","76.54","76.54","76.54","1 through 10","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.20","572.40","WELLPOINT [1015]","HB CH WELLPOINT","594.61","77.91","","273.64","94.28","1367.51","138","339.24","594.61","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.20","572.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","452.58","59.3","","720.78","230.14","2010.94","427","381.6","598.73","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.20","572.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","452.58","59.3","","344.45","344.45","344.45","1 through 10","381.6","598.73","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.20","572.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","598.73","78.45","","1120.13","1120.13","1120.13","1 through 10","381.6","598.73","percent of total billed charges",""
"SCREW BONE 4MM 3X16 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10030139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.20","572.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","598.73","78.45","","456.17","105.33","1284.66","242","381.6","598.73","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","464.71","67.87","1012.10","221","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","293.04","293.04","293.04","11","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","983.89","983.89","983.89","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","130.50","58","","677.18","677.18","677.18","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","140.63","62.5","","46.58","46.58","46.58","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","747.15","747.15","747.15","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","1141.67","481.21","1141.67","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","76.54","76.54","76.54","1 through 10","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","273.64","94.28","1367.51","138","100.01","175.3","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","720.78","230.14","2010.94","427","112.5","176.51","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","133.43","59.3","","344.45","344.45","344.45","1 through 10","112.5","176.51","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","1120.13","1120.13","1120.13","1 through 10","112.5","176.51","percent of total billed charges",""
"SCREW BONE 4X12MM TITANIUM SELF TAPPING VARIABLE ANGLE","SUP-ITM-10146126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","456.17","105.33","1284.66","242","112.5","176.51","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","AETNA [1001]","HB CH AETNA HMO / PPO","195.43","58.3","","464.71","67.87","1012.10","221","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","195.43","58.3","","293.04","293.04","293.04","11","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.67","53","","983.89","983.89","983.89","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","194.43","58","","677.18","677.18","677.18","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","209.51","62.5","","46.58","46.58","46.58","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.71","73","","747.15","747.15","747.15","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.01","44.45","","1141.67","481.21","1141.67","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.01","44.45","","76.54","76.54","76.54","1 through 10","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","WELLPOINT [1015]","HB CH WELLPOINT","261.17","77.91","","273.64","94.28","1367.51","138","149.01","261.17","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.79","59.3","","720.78","230.14","2010.94","427","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","198.79","59.3","","344.45","344.45","344.45","1 through 10","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","262.98","78.45","","1120.13","1120.13","1120.13","1 through 10","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.98","78.45","","456.17","105.33","1284.66","242","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","464.71","67.87","1012.10","221","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","293.04","293.04","293.04","11","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","983.89","983.89","983.89","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","191.40","58","","677.18","677.18","677.18","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","206.25","62.5","","46.58","46.58","46.58","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","747.15","747.15","747.15","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","1141.67","481.21","1141.67","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","76.54","76.54","76.54","1 through 10","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","273.64","94.28","1367.51","138","146.69","257.1","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","720.78","230.14","2010.94","427","165","258.89","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","195.69","59.3","","344.45","344.45","344.45","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","1120.13","1120.13","1120.13","1 through 10","165","258.89","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","456.17","105.33","1284.66","242","165","258.89","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","AETNA [1001]","HB CH AETNA HMO / PPO","213.80","58.3","","464.71","67.87","1012.10","221","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","213.80","58.3","","293.04","293.04","293.04","11","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","194.36","53","","983.89","983.89","983.89","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","212.70","58","","677.18","677.18","677.18","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","229.20","62.5","","46.58","46.58","46.58","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","267.71","73","","747.15","747.15","747.15","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.01","44.45","","1141.67","481.21","1141.67","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.01","44.45","","76.54","76.54","76.54","1 through 10","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","WELLPOINT [1015]","HB CH WELLPOINT","285.71","77.91","","273.64","94.28","1367.51","138","163.01","285.71","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.46","59.3","","720.78","230.14","2010.94","427","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","217.46","59.3","","344.45","344.45","344.45","1 through 10","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","287.69","78.45","","1120.13","1120.13","1120.13","1 through 10","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.69","78.45","","456.17","105.33","1284.66","242","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","464.71","67.87","1012.10","221","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","293.04","293.04","293.04","11","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","983.89","983.89","983.89","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","287.10","58","","677.18","677.18","677.18","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","46.58","46.58","46.58","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","747.15","747.15","747.15","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","1141.67","481.21","1141.67","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","76.54","76.54","76.54","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","273.64","94.28","1367.51","138","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","720.78","230.14","2010.94","427","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","293.54","59.3","","344.45","344.45","344.45","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","1120.13","1120.13","1120.13","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","456.17","105.33","1284.66","242","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","AETNA [1001]","HB CH AETNA HMO / PPO","54.36","58.3","","464.71","67.87","1012.10","221","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","54.36","58.3","","293.04","293.04","293.04","11","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","49.42","53","","983.89","983.89","983.89","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","54.08","58","","677.18","677.18","677.18","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","58.28","62.5","","46.58","46.58","46.58","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","68.07","73","","747.15","747.15","747.15","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.45","44.45","","1141.67","481.21","1141.67","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.45","44.45","","76.54","76.54","76.54","1 through 10","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","WELLPOINT [1015]","HB CH WELLPOINT","72.64","77.91","","273.64","94.28","1367.51","138","41.45","72.64","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.29","59.3","","720.78","230.14","2010.94","427","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","55.29","59.3","","344.45","344.45","344.45","1 through 10","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","73.15","78.45","","1120.13","1120.13","1120.13","1 through 10","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.15","78.45","","456.17","105.33","1284.66","242","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","AETNA [1001]","HB CH AETNA HMO / PPO","407.52","58.3","","464.71","67.87","1012.10","221","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","407.52","58.3","","293.04","293.04","293.04","11","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","370.47","53","","983.89","983.89","983.89","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","405.42","58","","677.18","677.18","677.18","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","436.88","62.5","","46.58","46.58","46.58","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","747.15","747.15","747.15","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.71","44.45","","1141.67","481.21","1141.67","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.71","44.45","","76.54","76.54","76.54","1 through 10","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","WELLPOINT [1015]","HB CH WELLPOINT","544.59","77.91","","273.64","94.28","1367.51","138","310.71","544.59","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","414.51","59.3","","720.78","230.14","2010.94","427","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","414.51","59.3","","344.45","344.45","344.45","1 through 10","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","548.37","78.45","","1120.13","1120.13","1120.13","1 through 10","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X28MM DARCO TI COMPRESSION SHORT","SUP-ITM-10133613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","548.37","78.45","","456.17","105.33","1284.66","242","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","AETNA [1001]","HB CH AETNA HMO / PPO","2164.39","58.3","","464.71","67.87","1012.10","221","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2164.39","58.3","","293.04","293.04","293.04","11","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1967.63","53","","983.89","983.89","983.89","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2153.25","58","","677.18","677.18","677.18","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2320.31","62.5","","46.58","46.58","46.58","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2710.13","73","","747.15","747.15","747.15","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.21","44.45","","1141.67","481.21","1141.67","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.21","44.45","","76.54","76.54","76.54","1 through 10","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","both","","","3712.50","2784.37","WELLPOINT [1015]","HB CH WELLPOINT","2892.41","77.91","","273.64","94.28","1367.51","138","1650.21","2892.41","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2201.51","59.3","","720.78","230.14","2010.94","427","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2201.51","59.3","","344.45","344.45","344.45","1 through 10","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2912.46","78.45","","1120.13","1120.13","1120.13","1 through 10","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 4X34MM COMPRESSION HEADLESS OSSIOFIBER","SUP-ITM-10304328","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3712.50","2784.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2912.46","78.45","","456.17","105.33","1284.66","242","1856.25","2912.46","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","AETNA [1001]","HB CH AETNA HMO / PPO","313.07","58.3","","464.71","67.87","1012.10","221","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","313.07","58.3","","293.04","293.04","293.04","11","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.61","53","","983.89","983.89","983.89","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","311.46","58","","677.18","677.18","677.18","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","335.63","62.5","","46.58","46.58","46.58","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","392.01","73","","747.15","747.15","747.15","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.70","44.45","","1141.67","481.21","1141.67","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.70","44.45","","76.54","76.54","76.54","1 through 10","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","WELLPOINT [1015]","HB CH WELLPOINT","418.38","77.91","","273.64","94.28","1367.51","138","238.7","418.38","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.44","59.3","","720.78","230.14","2010.94","427","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","318.44","59.3","","344.45","344.45","344.45","1 through 10","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","421.28","78.45","","1120.13","1120.13","1120.13","1 through 10","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X35MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","421.28","78.45","","456.17","105.33","1284.66","242","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","AETNA [1001]","HB CH AETNA HMO / PPO","505.57","58.3","","464.71","67.87","1012.10","221","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","505.57","58.3","","293.04","293.04","293.04","11","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","459.61","53","","983.89","983.89","983.89","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","502.96","58","","677.18","677.18","677.18","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","541.99","62.5","","46.58","46.58","46.58","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","633.04","73","","747.15","747.15","747.15","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.46","44.45","","1141.67","481.21","1141.67","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.46","44.45","","76.54","76.54","76.54","1 through 10","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","WELLPOINT [1015]","HB CH WELLPOINT","675.62","77.91","","273.64","94.28","1367.51","138","385.46","675.62","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","514.24","59.3","","720.78","230.14","2010.94","427","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","514.24","59.3","","344.45","344.45","344.45","1 through 10","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","680.30","78.45","","1120.13","1120.13","1120.13","1 through 10","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X40MM ASNIS III CANNULATED SS SELF TAPPING PARTIAL THREAD","SUP-ITM-10033996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","680.30","78.45","","456.17","105.33","1284.66","242","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","AETNA [1001]","HB CH AETNA HMO / PPO","379.97","58.3","","464.71","67.87","1012.10","221","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.97","58.3","","293.04","293.04","293.04","11","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.43","53","","983.89","983.89","983.89","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","378.02","58","","677.18","677.18","677.18","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","407.34","62.5","","46.58","46.58","46.58","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.78","73","","747.15","747.15","747.15","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.70","44.45","","1141.67","481.21","1141.67","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.70","44.45","","76.54","76.54","76.54","1 through 10","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","WELLPOINT [1015]","HB CH WELLPOINT","507.78","77.91","","273.64","94.28","1367.51","138","289.7","507.78","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.49","59.3","","720.78","230.14","2010.94","427","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","386.49","59.3","","344.45","344.45","344.45","1 through 10","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","511.30","78.45","","1120.13","1120.13","1120.13","1 through 10","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.30","78.45","","456.17","105.33","1284.66","242","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","464.71","67.87","1012.10","221","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","293.04","293.04","293.04","11","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","983.89","983.89","983.89","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","287.10","58","","677.18","677.18","677.18","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","309.38","62.5","","46.58","46.58","46.58","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","747.15","747.15","747.15","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","1141.67","481.21","1141.67","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","76.54","76.54","76.54","1 through 10","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","273.64","94.28","1367.51","138","220.03","385.65","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","720.78","230.14","2010.94","427","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","293.54","59.3","","344.45","344.45","344.45","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","1120.13","1120.13","1120.13","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","456.17","105.33","1284.66","242","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","AETNA [1001]","HB CH AETNA HMO / PPO","47.89","58.3","","464.71","67.87","1012.10","221","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.89","58.3","","293.04","293.04","293.04","11","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","43.53","53","","983.89","983.89","983.89","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","47.64","58","","677.18","677.18","677.18","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","51.34","62.5","","46.58","46.58","46.58","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.96","73","","747.15","747.15","747.15","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.51","44.45","","1141.67","481.21","1141.67","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.51","44.45","","76.54","76.54","76.54","1 through 10","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","WELLPOINT [1015]","HB CH WELLPOINT","64.00","77.91","","273.64","94.28","1367.51","138","36.51","64","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.71","59.3","","720.78","230.14","2010.94","427","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","48.71","59.3","","344.45","344.45","344.45","1 through 10","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","64.44","78.45","","1120.13","1120.13","1120.13","1 through 10","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","64.44","78.45","","456.17","105.33","1284.66","242","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","AETNA [1001]","HB CH AETNA HMO / PPO","101.11","58.3","","464.71","67.87","1012.10","221","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","101.11","58.3","","293.04","293.04","293.04","11","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.92","53","","983.89","983.89","983.89","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","100.59","58","","677.18","677.18","677.18","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","108.39","62.5","","46.58","46.58","46.58","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","747.15","747.15","747.15","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","1141.67","481.21","1141.67","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","76.54","76.54","76.54","1 through 10","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","WELLPOINT [1015]","HB CH WELLPOINT","135.12","77.91","","273.64","94.28","1367.51","138","77.09","135.12","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.84","59.3","","720.78","230.14","2010.94","427","86.72","136.06","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.84","59.3","","344.45","344.45","344.45","1 through 10","86.72","136.06","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","1120.13","1120.13","1120.13","1 through 10","86.72","136.06","percent of total billed charges",""
"SCREW BONE 4X50MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","456.17","105.33","1284.66","242","86.72","136.06","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","AETNA [1001]","HB CH AETNA HMO / PPO","559.87","58.3","","464.71","67.87","1012.10","221","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","559.87","58.3","","293.04","293.04","293.04","11","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.97","53","","983.89","983.89","983.89","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","556.99","58","","677.18","677.18","677.18","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","600.21","62.5","","46.58","46.58","46.58","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","701.04","73","","747.15","747.15","747.15","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.87","44.45","","1141.67","481.21","1141.67","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.87","44.45","","76.54","76.54","76.54","1 through 10","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","WELLPOINT [1015]","HB CH WELLPOINT","748.19","77.91","","273.64","94.28","1367.51","138","426.87","748.19","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","569.48","59.3","","720.78","230.14","2010.94","427","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","569.48","59.3","","344.45","344.45","344.45","1 through 10","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","753.38","78.45","","1120.13","1120.13","1120.13","1 through 10","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.38","78.45","","456.17","105.33","1284.66","242","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","AETNA [1001]","HB CH AETNA HMO / PPO","48.53","58.3","","464.71","67.87","1012.10","221","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.53","58.3","","293.04","293.04","293.04","11","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.12","53","","983.89","983.89","983.89","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","48.29","58","","677.18","677.18","677.18","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","52.03","62.5","","46.58","46.58","46.58","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","60.77","73","","747.15","747.15","747.15","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.00","44.45","","1141.67","481.21","1141.67","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.00","44.45","","76.54","76.54","76.54","1 through 10","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","WELLPOINT [1015]","HB CH WELLPOINT","64.86","77.91","","273.64","94.28","1367.51","138","37","64.86","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.37","59.3","","720.78","230.14","2010.94","427","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","49.37","59.3","","344.45","344.45","344.45","1 through 10","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","65.31","78.45","","1120.13","1120.13","1120.13","1 through 10","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.31","78.45","","456.17","105.33","1284.66","242","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","AETNA [1001]","HB CH AETNA HMO / PPO","86.72","58.3","","464.71","67.87","1012.10","221","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","86.72","58.3","","293.04","293.04","293.04","11","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.83","53","","983.89","983.89","983.89","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","86.27","58","","677.18","677.18","677.18","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","92.96","62.5","","46.58","46.58","46.58","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","108.58","73","","747.15","747.15","747.15","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.11","44.45","","1141.67","481.21","1141.67","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.11","44.45","","76.54","76.54","76.54","1 through 10","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.74","111.55","WELLPOINT [1015]","HB CH WELLPOINT","115.88","77.91","","273.64","94.28","1367.51","138","66.11","115.88","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.74","111.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.20","59.3","","720.78","230.14","2010.94","427","74.37","116.69","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.74","111.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.20","59.3","","344.45","344.45","344.45","1 through 10","74.37","116.69","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.74","111.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","116.69","78.45","","1120.13","1120.13","1120.13","1 through 10","74.37","116.69","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.74","111.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.69","78.45","","456.17","105.33","1284.66","242","74.37","116.69","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","AETNA [1001]","HB CH AETNA HMO / PPO","108.72","58.3","","464.71","67.87","1012.10","221","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.72","58.3","","293.04","293.04","293.04","11","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.83","53","","983.89","983.89","983.89","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","108.16","58","","677.18","677.18","677.18","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","116.55","62.5","","46.58","46.58","46.58","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","136.13","73","","747.15","747.15","747.15","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.89","44.45","","1141.67","481.21","1141.67","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.89","44.45","","76.54","76.54","76.54","1 through 10","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","WELLPOINT [1015]","HB CH WELLPOINT","145.29","77.91","","273.64","94.28","1367.51","138","82.89","145.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.58","59.3","","720.78","230.14","2010.94","427","93.24","146.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","110.58","59.3","","344.45","344.45","344.45","1 through 10","93.24","146.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","146.29","78.45","","1120.13","1120.13","1120.13","1 through 10","93.24","146.29","percent of total billed charges",""
"SCREW BONE 4X80MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10004523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","146.29","78.45","","456.17","105.33","1284.66","242","93.24","146.29","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","AETNA [1001]","HB CH AETNA HMO / PPO","513.05","58.3","","464.71","67.87","1012.10","221","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.05","58.3","","293.04","293.04","293.04","11","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.41","53","","983.89","983.89","983.89","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","510.41","58","","677.18","677.18","677.18","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","550.01","62.5","","46.58","46.58","46.58","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","747.15","747.15","747.15","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","1141.67","481.21","1141.67","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","76.54","76.54","76.54","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","WELLPOINT [1015]","HB CH WELLPOINT","685.62","77.91","","273.64","94.28","1367.51","138","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.85","59.3","","720.78","230.14","2010.94","427","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","521.85","59.3","","344.45","344.45","344.45","1 through 10","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","1120.13","1120.13","1120.13","1 through 10","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","456.17","105.33","1284.66","242","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","AETNA [1001]","HB CH AETNA HMO / PPO","558.00","58.3","","464.71","67.87","1012.10","221","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","558.00","58.3","","293.04","293.04","293.04","11","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","507.27","53","","983.89","983.89","983.89","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","555.13","58","","677.18","677.18","677.18","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","598.20","62.5","","46.58","46.58","46.58","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","698.70","73","","747.15","747.15","747.15","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.44","44.45","","1141.67","481.21","1141.67","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.44","44.45","","76.54","76.54","76.54","1 through 10","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.12","717.84","WELLPOINT [1015]","HB CH WELLPOINT","745.69","77.91","","273.64","94.28","1367.51","138","425.44","745.69","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","567.57","59.3","","720.78","230.14","2010.94","427","478.56","750.86","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","567.57","59.3","","344.45","344.45","344.45","1 through 10","478.56","750.86","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","750.86","78.45","","1120.13","1120.13","1120.13","1 through 10","478.56","750.86","percent of total billed charges",""
"SCREW BONE 5.0X85MM T2 TITANIUM CONDYLAR","SUP-ITM-10033859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.12","717.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","750.86","78.45","","456.17","105.33","1284.66","242","478.56","750.86","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","AETNA [1001]","HB CH AETNA HMO / PPO","585.92","58.3","","464.71","67.87","1012.10","221","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.92","58.3","","293.04","293.04","293.04","11","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.65","53","","983.89","983.89","983.89","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","582.90","58","","677.18","677.18","677.18","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","628.13","62.5","","46.58","46.58","46.58","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","747.15","747.15","747.15","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","1141.67","481.21","1141.67","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","76.54","76.54","76.54","1 through 10","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","WELLPOINT [1015]","HB CH WELLPOINT","783.00","77.91","","273.64","94.28","1367.51","138","446.72","783","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.97","59.3","","720.78","230.14","2010.94","427","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","595.97","59.3","","344.45","344.45","344.45","1 through 10","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","1120.13","1120.13","1120.13","1 through 10","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","456.17","105.33","1284.66","242","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","2190.90","412.50","9264.59","16","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","678.60","58","","1903.20","1903.20","3826.66","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","731.25","62.5","","2186.25","2186.25","2186.25","32","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","5556.60","5556.60","5556.60","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","1955.15","885.83","3150.40","26","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","831.03","253.22","2394.88","18","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X25MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117072","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","2481.69","1563.74","8149.28","1 through 10","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","464.71","67.87","1012.10","221","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","293.04","293.04","293.04","11","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","983.89","983.89","983.89","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","243.74","58","","677.18","677.18","677.18","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","262.65","62.5","","46.58","46.58","46.58","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","747.15","747.15","747.15","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","1141.67","481.21","1141.67","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","76.54","76.54","76.54","1 through 10","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","273.64","94.28","1367.51","138","186.8","327.41","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","720.78","230.14","2010.94","427","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","249.20","59.3","","344.45","344.45","344.45","1 through 10","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","1120.13","1120.13","1120.13","1 through 10","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","456.17","105.33","1284.66","242","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","AETNA [1001]","HB CH AETNA HMO / PPO","397.02","58.3","","464.71","67.87","1012.10","221","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","397.02","58.3","","293.04","293.04","293.04","11","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","360.93","53","","983.89","983.89","983.89","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","394.98","58","","677.18","677.18","677.18","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","425.63","62.5","","46.58","46.58","46.58","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","497.13","73","","747.15","747.15","747.15","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.70","44.45","","1141.67","481.21","1141.67","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.70","44.45","","76.54","76.54","76.54","1 through 10","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.00","510.75","WELLPOINT [1015]","HB CH WELLPOINT","530.57","77.91","","273.64","94.28","1367.51","138","302.7","530.57","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.00","510.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.83","59.3","","720.78","230.14","2010.94","427","340.5","534.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.00","510.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","403.83","59.3","","344.45","344.45","344.45","1 through 10","340.5","534.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.00","510.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","534.24","78.45","","1120.13","1120.13","1120.13","1 through 10","340.5","534.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM MAXLOCK TI CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.00","510.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","534.24","78.45","","456.17","105.33","1284.66","242","340.5","534.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","2190.90","412.50","9264.59","16","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","678.60","58","","1903.20","1903.20","3826.66","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","731.25","62.5","","2186.25","2186.25","2186.25","32","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","5556.60","5556.60","5556.60","1 through 10","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","1955.15","885.83","3150.40","26","520.07","911.55","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","831.03","253.22","2394.88","18","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","2481.69","1563.74","8149.28","1 through 10","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","464.71","67.87","1012.10","221","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","293.04","293.04","293.04","11","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","983.89","983.89","983.89","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1409.40","58","","677.18","677.18","677.18","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1518.75","62.5","","46.58","46.58","46.58","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","747.15","747.15","747.15","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","1141.67","481.21","1141.67","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","76.54","76.54","76.54","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","273.64","94.28","1367.51","138","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","720.78","230.14","2010.94","427","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1440.99","59.3","","344.45","344.45","344.45","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1120.13","1120.13","1120.13","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X45MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10021623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","456.17","105.33","1284.66","242","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","AETNA [1001]","HB CH AETNA HMO / PPO","261.21","58.3","","464.71","67.87","1012.10","221","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","261.21","58.3","","293.04","293.04","293.04","11","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.47","53","","983.89","983.89","983.89","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","259.87","58","","677.18","677.18","677.18","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","280.03","62.5","","46.58","46.58","46.58","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.08","73","","747.15","747.15","747.15","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.16","44.45","","1141.67","481.21","1141.67","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.16","44.45","","76.54","76.54","76.54","1 through 10","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","WELLPOINT [1015]","HB CH WELLPOINT","349.08","77.91","","273.64","94.28","1367.51","138","199.16","349.08","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","265.69","59.3","","720.78","230.14","2010.94","427","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","265.69","59.3","","344.45","344.45","344.45","1 through 10","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","351.50","78.45","","1120.13","1120.13","1120.13","1 through 10","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X55MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.50","78.45","","456.17","105.33","1284.66","242","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","464.71","67.87","1012.10","221","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","293.04","293.04","293.04","11","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","983.89","983.89","983.89","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1409.40","58","","677.18","677.18","677.18","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1518.75","62.5","","46.58","46.58","46.58","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","747.15","747.15","747.15","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","1141.67","481.21","1141.67","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","76.54","76.54","76.54","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","273.64","94.28","1367.51","138","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","720.78","230.14","2010.94","427","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1440.99","59.3","","344.45","344.45","344.45","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1120.13","1120.13","1120.13","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","456.17","105.33","1284.66","242","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","2190.90","412.50","9264.59","16","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1409.40","58","","1903.20","1903.20","3826.66","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1518.75","62.5","","2186.25","2186.25","2186.25","32","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","5556.60","5556.60","5556.60","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","1955.15","885.83","3150.40","26","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","831.03","253.22","2394.88","18","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","2481.69","1563.74","8149.28","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","2190.90","412.50","9264.59","16","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1409.40","58","","1903.20","1903.20","3826.66","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1518.75","62.5","","2186.25","2186.25","2186.25","32","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","5556.60","5556.60","5556.60","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","1955.15","885.83","3150.40","26","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","831.03","253.22","2394.88","18","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","2481.69","1563.74","8149.28","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"SCREW BONE 5.5X9.0X50MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM DUAL INNER","SUP-ITM-10045713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","AETNA [1001]","HB CH AETNA HMO / PPO","292.08","58.3","","464.71","67.87","1012.10","221","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","292.08","58.3","","293.04","293.04","293.04","11","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.53","53","","983.89","983.89","983.89","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","290.58","58","","677.18","677.18","677.18","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","313.13","62.5","","46.58","46.58","46.58","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","365.73","73","","747.15","747.15","747.15","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.69","44.45","","1141.67","481.21","1141.67","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.69","44.45","","76.54","76.54","76.54","1 through 10","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.00","375.75","WELLPOINT [1015]","HB CH WELLPOINT","390.33","77.91","","273.64","94.28","1367.51","138","222.69","390.33","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.00","375.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","297.09","59.3","","720.78","230.14","2010.94","427","250.5","393.03","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","297.09","59.3","","344.45","344.45","344.45","1 through 10","250.5","393.03","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","393.03","78.45","","1120.13","1120.13","1120.13","1 through 10","250.5","393.03","percent of total billed charges",""
"SCREW BONE 5MM 30MM SCARLET AL-T BODY FUSION DEVICE LUMBAR","SUP-ITM-10236124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","393.03","78.45","","456.17","105.33","1284.66","242","250.5","393.03","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","AETNA [1001]","HB CH AETNA HMO / PPO","148.32","58.3","","464.71","67.87","1012.10","221","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.32","58.3","","293.04","293.04","293.04","11","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.83","53","","983.89","983.89","983.89","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","147.55","58","","677.18","677.18","677.18","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","159.00","62.5","","46.58","46.58","46.58","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","185.71","73","","747.15","747.15","747.15","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.08","44.45","","1141.67","481.21","1141.67","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.08","44.45","","76.54","76.54","76.54","1 through 10","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.40","190.80","WELLPOINT [1015]","HB CH WELLPOINT","198.20","77.91","","273.64","94.28","1367.51","138","113.08","198.2","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.40","190.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.86","59.3","","720.78","230.14","2010.94","427","127.2","199.58","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.40","190.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","150.86","59.3","","344.45","344.45","344.45","1 through 10","127.2","199.58","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.40","190.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","199.58","78.45","","1120.13","1120.13","1120.13","1 through 10","127.2","199.58","percent of total billed charges",""
"SCREW BONE 5MM 3X18 ASNIS CANNULATED TITANIUM THREAD MICRO","SUP-ITM-10041330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.40","190.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","199.58","78.45","","456.17","105.33","1284.66","242","127.2","199.58","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","AETNA [1001]","HB CH AETNA HMO / PPO","176.67","58.3","","464.71","67.87","1012.10","221","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","176.67","58.3","","293.04","293.04","293.04","11","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","160.61","53","","983.89","983.89","983.89","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","175.76","58","","677.18","677.18","677.18","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","189.39","62.5","","46.58","46.58","46.58","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","221.21","73","","747.15","747.15","747.15","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.70","44.45","","1141.67","481.21","1141.67","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.70","44.45","","76.54","76.54","76.54","1 through 10","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","WELLPOINT [1015]","HB CH WELLPOINT","236.09","77.91","","273.64","94.28","1367.51","138","134.7","236.09","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","179.70","59.3","","720.78","230.14","2010.94","427","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","179.70","59.3","","344.45","344.45","344.45","1 through 10","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","237.73","78.45","","1120.13","1120.13","1120.13","1 through 10","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","237.73","78.45","","456.17","105.33","1284.66","242","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","AETNA [1001]","HB CH AETNA HMO / PPO","333.92","58.3","","464.71","67.87","1012.10","221","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","333.92","58.3","","293.04","293.04","293.04","11","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","303.56","53","","983.89","983.89","983.89","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","332.20","58","","677.18","677.18","677.18","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","357.98","62.5","","46.58","46.58","46.58","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","418.11","73","","747.15","747.15","747.15","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.59","44.45","","1141.67","481.21","1141.67","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.59","44.45","","76.54","76.54","76.54","1 through 10","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.76","429.57","WELLPOINT [1015]","HB CH WELLPOINT","446.24","77.91","","273.64","94.28","1367.51","138","254.59","446.24","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.76","429.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","339.65","59.3","","720.78","230.14","2010.94","427","286.38","449.33","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.76","429.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","339.65","59.3","","344.45","344.45","344.45","1 through 10","286.38","449.33","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.76","429.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","449.33","78.45","","1120.13","1120.13","1120.13","1 through 10","286.38","449.33","percent of total billed charges",""
"SCREW BONE 5X14MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.76","429.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","449.33","78.45","","456.17","105.33","1284.66","242","286.38","449.33","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","AETNA [1001]","HB CH AETNA HMO / PPO","119.77","58.3","","464.71","67.87","1012.10","221","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","119.77","58.3","","293.04","293.04","293.04","11","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","108.88","53","","983.89","983.89","983.89","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","119.16","58","","677.18","677.18","677.18","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","128.40","62.5","","46.58","46.58","46.58","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","149.97","73","","747.15","747.15","747.15","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.32","44.45","","1141.67","481.21","1141.67","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.32","44.45","","76.54","76.54","76.54","1 through 10","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","WELLPOINT [1015]","HB CH WELLPOINT","160.06","77.91","","273.64","94.28","1367.51","138","91.32","160.06","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.83","59.3","","720.78","230.14","2010.94","427","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","121.83","59.3","","344.45","344.45","344.45","1 through 10","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","161.17","78.45","","1120.13","1120.13","1120.13","1 through 10","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","161.17","78.45","","456.17","105.33","1284.66","242","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","1530.90","1160.93","1884.08","89","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","5253.92","5253.92","5253.92","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","132.24","58","","12181.47","12181.47","12181.47","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","142.50","62.5","","1350.68","1350.68","1350.68","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","1910.74","891.94","1910.74","1 through 10","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","1829.79","1561.50","2617.12","88","101.35","177.63","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","1359.46","1201.30","1689.00","61","114","178.87","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","135.20","59.3","","1718.92","1718.92","1718.92","1 through 10","114","178.87","percent of total billed charges",""
"SCREW BONE 5X18MM REVERSE RSP LOCKING","SUP-ITM-10206943","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","1910.74","1019.06","2344.84","74","114","178.87","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","AETNA [1001]","HB CH AETNA HMO / PPO","261.44","58.3","","464.71","67.87","1012.10","221","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","261.44","58.3","","293.04","293.04","293.04","11","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.67","53","","983.89","983.89","983.89","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","260.10","58","","677.18","677.18","677.18","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","280.28","62.5","","46.58","46.58","46.58","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.36","73","","747.15","747.15","747.15","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.33","44.45","","1141.67","481.21","1141.67","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.33","44.45","","76.54","76.54","76.54","1 through 10","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","WELLPOINT [1015]","HB CH WELLPOINT","349.38","77.91","","273.64","94.28","1367.51","138","199.33","349.38","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","265.92","59.3","","720.78","230.14","2010.94","427","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","265.92","59.3","","344.45","344.45","344.45","1 through 10","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","351.80","78.45","","1120.13","1120.13","1120.13","1 through 10","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.80","78.45","","456.17","105.33","1284.66","242","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","AETNA [1001]","HB CH AETNA HMO / PPO","355.73","58.3","","464.71","67.87","1012.10","221","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","355.73","58.3","","293.04","293.04","293.04","11","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","323.39","53","","983.89","983.89","983.89","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","353.90","58","","677.18","677.18","677.18","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","381.36","62.5","","46.58","46.58","46.58","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","445.42","73","","747.15","747.15","747.15","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.22","44.45","","1141.67","481.21","1141.67","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.22","44.45","","76.54","76.54","76.54","1 through 10","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","WELLPOINT [1015]","HB CH WELLPOINT","475.38","77.91","","273.64","94.28","1367.51","138","271.22","475.38","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","361.83","59.3","","720.78","230.14","2010.94","427","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","361.83","59.3","","344.45","344.45","344.45","1 through 10","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","478.68","78.45","","1120.13","1120.13","1120.13","1 through 10","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X30MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","478.68","78.45","","456.17","105.33","1284.66","242","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","AETNA [1001]","HB CH AETNA HMO / PPO","220.02","58.3","","464.71","67.87","1012.10","221","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","220.02","58.3","","293.04","293.04","293.04","11","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","200.02","53","","983.89","983.89","983.89","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","218.89","58","","677.18","677.18","677.18","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","235.88","62.5","","46.58","46.58","46.58","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","275.50","73","","747.15","747.15","747.15","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.75","44.45","","1141.67","481.21","1141.67","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.75","44.45","","76.54","76.54","76.54","1 through 10","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","WELLPOINT [1015]","HB CH WELLPOINT","294.03","77.91","","273.64","94.28","1367.51","138","167.75","294.03","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.80","59.3","","720.78","230.14","2010.94","427","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","223.80","59.3","","344.45","344.45","344.45","1 through 10","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","296.07","78.45","","1120.13","1120.13","1120.13","1 through 10","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","296.07","78.45","","456.17","105.33","1284.66","242","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","AETNA [1001]","HB CH AETNA HMO / PPO","284.28","58.3","","464.71","67.87","1012.10","221","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.28","58.3","","293.04","293.04","293.04","11","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.44","53","","983.89","983.89","983.89","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.82","58","","677.18","677.18","677.18","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.76","62.5","","46.58","46.58","46.58","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.96","73","","747.15","747.15","747.15","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","1141.67","481.21","1141.67","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","76.54","76.54","76.54","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","WELLPOINT [1015]","HB CH WELLPOINT","379.90","77.91","","273.64","94.28","1367.51","138","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.16","59.3","","720.78","230.14","2010.94","427","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","289.16","59.3","","344.45","344.45","344.45","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","1120.13","1120.13","1120.13","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","456.17","105.33","1284.66","242","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","AETNA [1001]","HB CH AETNA HMO / PPO","284.74","58.3","","464.71","67.87","1012.10","221","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.74","58.3","","293.04","293.04","293.04","11","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.85","53","","983.89","983.89","983.89","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","283.27","58","","677.18","677.18","677.18","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","305.25","62.5","","46.58","46.58","46.58","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.53","73","","747.15","747.15","747.15","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.09","44.45","","1141.67","481.21","1141.67","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.09","44.45","","76.54","76.54","76.54","1 through 10","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","WELLPOINT [1015]","HB CH WELLPOINT","380.51","77.91","","273.64","94.28","1367.51","138","217.09","380.51","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.62","59.3","","720.78","230.14","2010.94","427","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","289.62","59.3","","344.45","344.45","344.45","1 through 10","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","383.15","78.45","","1120.13","1120.13","1120.13","1 through 10","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.15","78.45","","456.17","105.33","1284.66","242","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","AETNA [1001]","HB CH AETNA HMO / PPO","471.86","58.3","","464.71","67.87","1012.10","221","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.86","58.3","","293.04","293.04","293.04","11","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.97","53","","983.89","983.89","983.89","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","469.43","58","","677.18","677.18","677.18","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","505.86","62.5","","46.58","46.58","46.58","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","747.15","747.15","747.15","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","1141.67","481.21","1141.67","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","76.54","76.54","76.54","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","WELLPOINT [1015]","HB CH WELLPOINT","630.58","77.91","","273.64","94.28","1367.51","138","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.96","59.3","","720.78","230.14","2010.94","427","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","479.96","59.3","","344.45","344.45","344.45","1 through 10","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","1120.13","1120.13","1120.13","1 through 10","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X40MM AXSOS TITANIUM LOCKING","SUP-ITM-10139260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","456.17","105.33","1284.66","242","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","464.71","67.87","1012.10","221","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","293.04","293.04","293.04","11","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","983.89","983.89","983.89","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","93.96","58","","677.18","677.18","677.18","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","101.25","62.5","","46.58","46.58","46.58","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","747.15","747.15","747.15","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","1141.67","481.21","1141.67","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","76.54","76.54","76.54","1 through 10","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","273.64","94.28","1367.51","138","72.01","126.21","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","720.78","230.14","2010.94","427","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","96.07","59.3","","344.45","344.45","344.45","1 through 10","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","1120.13","1120.13","1120.13","1 through 10","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","456.17","105.33","1284.66","242","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","AETNA [1001]","HB CH AETNA HMO / PPO","513.05","58.3","","464.71","67.87","1012.10","221","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.05","58.3","","293.04","293.04","293.04","11","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.41","53","","983.89","983.89","983.89","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","510.41","58","","677.18","677.18","677.18","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","550.01","62.5","","46.58","46.58","46.58","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","747.15","747.15","747.15","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","1141.67","481.21","1141.67","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","76.54","76.54","76.54","1 through 10","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","WELLPOINT [1015]","HB CH WELLPOINT","685.62","77.91","","273.64","94.28","1367.51","138","391.17","685.62","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.85","59.3","","720.78","230.14","2010.94","427","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","521.85","59.3","","344.45","344.45","344.45","1 through 10","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","1120.13","1120.13","1120.13","1 through 10","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","456.17","105.33","1284.66","242","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","AETNA [1001]","HB CH AETNA HMO / PPO","284.28","58.3","","464.71","67.87","1012.10","221","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.28","58.3","","293.04","293.04","293.04","11","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.44","53","","983.89","983.89","983.89","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.82","58","","677.18","677.18","677.18","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.76","62.5","","46.58","46.58","46.58","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.96","73","","747.15","747.15","747.15","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","1141.67","481.21","1141.67","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","76.54","76.54","76.54","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","WELLPOINT [1015]","HB CH WELLPOINT","379.90","77.91","","273.64","94.28","1367.51","138","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.16","59.3","","720.78","230.14","2010.94","427","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","289.16","59.3","","344.45","344.45","344.45","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","1120.13","1120.13","1120.13","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","456.17","105.33","1284.66","242","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","AETNA [1001]","HB CH AETNA HMO / PPO","263.98","58.3","","464.71","67.87","1012.10","221","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","263.98","58.3","","293.04","293.04","293.04","11","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","239.98","53","","983.89","983.89","983.89","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","262.62","58","","677.18","677.18","677.18","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","282.99","62.5","","46.58","46.58","46.58","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","330.54","73","","747.15","747.15","747.15","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.27","44.45","","1141.67","481.21","1141.67","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.27","44.45","","76.54","76.54","76.54","1 through 10","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","452.79","339.59","WELLPOINT [1015]","HB CH WELLPOINT","352.77","77.91","","273.64","94.28","1367.51","138","201.27","352.77","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","452.79","339.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.50","59.3","","720.78","230.14","2010.94","427","226.4","355.21","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","452.79","339.59","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","268.50","59.3","","344.45","344.45","344.45","1 through 10","226.4","355.21","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","452.79","339.59","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","355.21","78.45","","1120.13","1120.13","1120.13","1 through 10","226.4","355.21","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","452.79","339.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","355.21","78.45","","456.17","105.33","1284.66","242","226.4","355.21","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","AETNA [1001]","HB CH AETNA HMO / PPO","284.28","58.3","","464.71","67.87","1012.10","221","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.28","58.3","","293.04","293.04","293.04","11","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.44","53","","983.89","983.89","983.89","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.82","58","","677.18","677.18","677.18","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.76","62.5","","46.58","46.58","46.58","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.96","73","","747.15","747.15","747.15","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","1141.67","481.21","1141.67","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.75","44.45","","76.54","76.54","76.54","1 through 10","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.62","365.71","WELLPOINT [1015]","HB CH WELLPOINT","379.90","77.91","","273.64","94.28","1367.51","138","216.75","379.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.16","59.3","","720.78","230.14","2010.94","427","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","289.16","59.3","","344.45","344.45","344.45","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","1120.13","1120.13","1120.13","1 through 10","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.62","365.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.54","78.45","","456.17","105.33","1284.66","242","243.81","382.54","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","AETNA [1001]","HB CH AETNA HMO / PPO","471.86","58.3","","464.71","67.87","1012.10","221","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.86","58.3","","293.04","293.04","293.04","11","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.97","53","","983.89","983.89","983.89","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","469.43","58","","677.18","677.18","677.18","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","505.86","62.5","","46.58","46.58","46.58","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","747.15","747.15","747.15","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","1141.67","481.21","1141.67","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","76.54","76.54","76.54","1 through 10","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","WELLPOINT [1015]","HB CH WELLPOINT","630.58","77.91","","273.64","94.28","1367.51","138","359.76","630.58","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.96","59.3","","720.78","230.14","2010.94","427","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","479.96","59.3","","344.45","344.45","344.45","1 through 10","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","1120.13","1120.13","1120.13","1 through 10","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X65MM AXSOS TITANIUM LOCKING","SUP-ITM-10139262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","456.17","105.33","1284.66","242","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","AETNA [1001]","HB CH AETNA HMO / PPO","265.32","58.3","","464.71","67.87","1012.10","221","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","265.32","58.3","","293.04","293.04","293.04","11","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.20","53","","983.89","983.89","983.89","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","263.96","58","","677.18","677.18","677.18","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","284.44","62.5","","46.58","46.58","46.58","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","332.22","73","","747.15","747.15","747.15","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.29","44.45","","1141.67","481.21","1141.67","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.29","44.45","","76.54","76.54","76.54","1 through 10","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","WELLPOINT [1015]","HB CH WELLPOINT","354.57","77.91","","273.64","94.28","1367.51","138","202.29","354.57","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","269.87","59.3","","720.78","230.14","2010.94","427","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","269.87","59.3","","344.45","344.45","344.45","1 through 10","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","357.03","78.45","","1120.13","1120.13","1120.13","1 through 10","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.03","78.45","","456.17","105.33","1284.66","242","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","AETNA [1001]","HB CH AETNA HMO / PPO","249.79","58.3","","464.71","67.87","1012.10","221","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","249.79","58.3","","293.04","293.04","293.04","11","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","227.08","53","","983.89","983.89","983.89","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","248.51","58","","677.18","677.18","677.18","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","267.79","62.5","","46.58","46.58","46.58","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","312.78","73","","747.15","747.15","747.15","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.45","44.45","","1141.67","481.21","1141.67","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.45","44.45","","76.54","76.54","76.54","1 through 10","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.46","321.34","WELLPOINT [1015]","HB CH WELLPOINT","333.81","77.91","","273.64","94.28","1367.51","138","190.45","333.81","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.46","321.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","254.08","59.3","","720.78","230.14","2010.94","427","214.23","336.13","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.46","321.34","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","254.08","59.3","","344.45","344.45","344.45","1 through 10","214.23","336.13","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.46","321.34","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","336.13","78.45","","1120.13","1120.13","1120.13","1 through 10","214.23","336.13","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.46","321.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","336.13","78.45","","456.17","105.33","1284.66","242","214.23","336.13","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","AETNA [1001]","HB CH AETNA HMO / PPO","256.26","58.3","","464.71","67.87","1012.10","221","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","256.26","58.3","","293.04","293.04","293.04","11","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","232.97","53","","983.89","983.89","983.89","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","254.94","58","","677.18","677.18","677.18","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","274.73","62.5","","46.58","46.58","46.58","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","320.88","73","","747.15","747.15","747.15","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.38","44.45","","1141.67","481.21","1141.67","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.38","44.45","","76.54","76.54","76.54","1 through 10","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.56","329.67","WELLPOINT [1015]","HB CH WELLPOINT","342.46","77.91","","273.64","94.28","1367.51","138","195.38","342.46","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.56","329.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","260.66","59.3","","720.78","230.14","2010.94","427","219.78","344.83","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.56","329.67","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","260.66","59.3","","344.45","344.45","344.45","1 through 10","219.78","344.83","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.56","329.67","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","344.83","78.45","","1120.13","1120.13","1120.13","1 through 10","219.78","344.83","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.56","329.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","344.83","78.45","","456.17","105.33","1284.66","242","219.78","344.83","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","AETNA [1001]","HB CH AETNA HMO / PPO","400.52","58.3","","464.71","67.87","1012.10","221","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","400.52","58.3","","293.04","293.04","293.04","11","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","364.11","53","","983.89","983.89","983.89","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","398.46","58","","677.18","677.18","677.18","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","429.38","62.5","","46.58","46.58","46.58","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","501.51","73","","747.15","747.15","747.15","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.37","44.45","","1141.67","481.21","1141.67","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.37","44.45","","76.54","76.54","76.54","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","WELLPOINT [1015]","HB CH WELLPOINT","535.24","77.91","","273.64","94.28","1367.51","138","305.37","535.24","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","407.39","59.3","","720.78","230.14","2010.94","427","343.5","538.95","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","407.39","59.3","","344.45","344.45","344.45","1 through 10","343.5","538.95","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","538.95","78.45","","1120.13","1120.13","1120.13","1 through 10","343.5","538.95","percent of total billed charges",""
"SCREW BONE 6 TO 8X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","538.95","78.45","","456.17","105.33","1284.66","242","343.5","538.95","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","464.71","67.87","1012.10","221","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","155.66","58.3","","293.04","293.04","293.04","11","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.51","53","","983.89","983.89","983.89","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","154.86","58","","677.18","677.18","677.18","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","166.88","62.5","","46.58","46.58","46.58","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","747.15","747.15","747.15","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","1141.67","481.21","1141.67","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","76.54","76.54","76.54","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","WELLPOINT [1015]","HB CH WELLPOINT","208.02","77.91","","273.64","94.28","1367.51","138","118.68","208.02","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.33","59.3","","720.78","230.14","2010.94","427","133.5","209.46","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.33","59.3","","344.45","344.45","344.45","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","1120.13","1120.13","1120.13","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW BONE 6.5MMX30MM STD CANCELLOUS CANNULATED NON LOCKING LOW PROFILE TITANIUM NON-STERILE","SUP-ITM-10027301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","456.17","105.33","1284.66","242","133.5","209.46","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","AETNA [1001]","HB CH AETNA HMO / PPO","69.79","58.3","","464.71","67.87","1012.10","221","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.79","58.3","","293.04","293.04","293.04","11","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.44","53","","983.89","983.89","983.89","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.43","58","","677.18","677.18","677.18","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","74.81","62.5","","46.58","46.58","46.58","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","747.15","747.15","747.15","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","1141.67","481.21","1141.67","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","76.54","76.54","76.54","1 through 10","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","WELLPOINT [1015]","HB CH WELLPOINT","93.26","77.91","","273.64","94.28","1367.51","138","53.21","93.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.98","59.3","","720.78","230.14","2010.94","427","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","70.98","59.3","","344.45","344.45","344.45","1 through 10","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","1120.13","1120.13","1120.13","1 through 10","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","456.17","105.33","1284.66","242","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","AETNA [1001]","HB CH AETNA HMO / PPO","194.87","58.3","","464.71","67.87","1012.10","221","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","194.87","58.3","","293.04","293.04","293.04","11","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.16","53","","983.89","983.89","983.89","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","193.87","58","","677.18","677.18","677.18","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","208.91","62.5","","46.58","46.58","46.58","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","747.15","747.15","747.15","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","1141.67","481.21","1141.67","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","76.54","76.54","76.54","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","WELLPOINT [1015]","HB CH WELLPOINT","260.42","77.91","","273.64","94.28","1367.51","138","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.22","59.3","","720.78","230.14","2010.94","427","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","198.22","59.3","","344.45","344.45","344.45","1 through 10","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","1120.13","1120.13","1120.13","1 through 10","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM NONLOCKING CENTRAL UNIVERSAL","SUP-ITM-10148151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","456.17","105.33","1284.66","242","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","AETNA [1001]","HB CH AETNA HMO / PPO","194.87","58.3","","464.71","67.87","1012.10","221","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","194.87","58.3","","293.04","293.04","293.04","11","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.16","53","","983.89","983.89","983.89","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","193.87","58","","677.18","677.18","677.18","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","208.91","62.5","","46.58","46.58","46.58","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","747.15","747.15","747.15","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","1141.67","481.21","1141.67","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","76.54","76.54","76.54","1 through 10","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","WELLPOINT [1015]","HB CH WELLPOINT","260.42","77.91","","273.64","94.28","1367.51","138","148.58","260.42","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.22","59.3","","720.78","230.14","2010.94","427","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","198.22","59.3","","344.45","344.45","344.45","1 through 10","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","1120.13","1120.13","1120.13","1 through 10","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X15MM SHOULDER GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10130301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","456.17","105.33","1284.66","242","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","464.71","67.87","1012.10","221","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","293.04","293.04","293.04","11","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","983.89","983.89","983.89","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.12","58","","677.18","677.18","677.18","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","71.25","62.5","","46.58","46.58","46.58","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","747.15","747.15","747.15","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","1141.67","481.21","1141.67","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","76.54","76.54","76.54","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","273.64","94.28","1367.51","138","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","720.78","230.14","2010.94","427","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.60","59.3","","344.45","344.45","344.45","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","1120.13","1120.13","1120.13","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","456.17","105.33","1284.66","242","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","AETNA [1001]","HB CH AETNA HMO / PPO","91.25","58.3","","464.71","67.87","1012.10","221","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.25","58.3","","293.04","293.04","293.04","11","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.95","53","","983.89","983.89","983.89","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","90.78","58","","677.18","677.18","677.18","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","97.82","62.5","","46.58","46.58","46.58","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.25","73","","747.15","747.15","747.15","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.57","44.45","","1141.67","481.21","1141.67","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.57","44.45","","76.54","76.54","76.54","1 through 10","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","WELLPOINT [1015]","HB CH WELLPOINT","121.94","77.91","","273.64","94.28","1367.51","138","69.57","121.94","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.81","59.3","","720.78","230.14","2010.94","427","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","92.81","59.3","","344.45","344.45","344.45","1 through 10","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","122.78","78.45","","1120.13","1120.13","1120.13","1 through 10","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.78","78.45","","456.17","105.33","1284.66","242","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB CH AETNA HMO / PPO","570.17","58.3","","464.71","67.87","1012.10","221","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.17","58.3","","293.04","293.04","293.04","11","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.34","53","","983.89","983.89","983.89","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","567.24","58","","677.18","677.18","677.18","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","611.25","62.5","","46.58","46.58","46.58","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","747.15","747.15","747.15","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.72","44.45","","1141.67","481.21","1141.67","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.72","44.45","","76.54","76.54","76.54","1 through 10","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB CH WELLPOINT","761.96","77.91","","273.64","94.28","1367.51","138","434.72","761.96","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","720.78","230.14","2010.94","427","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","579.95","59.3","","344.45","344.45","344.45","1 through 10","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","1120.13","1120.13","1120.13","1 through 10","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","456.17","105.33","1284.66","242","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","464.71","67.87","1012.10","221","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.94","58.3","","293.04","293.04","293.04","11","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.04","53","","983.89","983.89","983.89","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","97.44","58","","677.18","677.18","677.18","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","105.00","62.5","","46.58","46.58","46.58","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","122.64","73","","747.15","747.15","747.15","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.68","44.45","","1141.67","481.21","1141.67","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.68","44.45","","76.54","76.54","76.54","1 through 10","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","WELLPOINT [1015]","HB CH WELLPOINT","130.89","77.91","","273.64","94.28","1367.51","138","74.68","130.89","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","720.78","230.14","2010.94","427","84","131.8","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","99.62","59.3","","344.45","344.45","344.45","1 through 10","84","131.8","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","1120.13","1120.13","1120.13","1 through 10","84","131.8","percent of total billed charges",""
"SCREW BONE 6.5X40MM CANCELLOUS 3600.40.065","SUP-ITM-10283185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","456.17","105.33","1284.66","242","84","131.8","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","AETNA [1001]","HB CH AETNA HMO / PPO","1096.62","58.3","","464.71","67.87","1012.10","221","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1096.62","58.3","","293.04","293.04","293.04","11","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","996.93","53","","983.89","983.89","983.89","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1090.98","58","","677.18","677.18","677.18","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1175.63","62.5","","46.58","46.58","46.58","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1373.13","73","","747.15","747.15","747.15","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","836.10","44.45","","1141.67","481.21","1141.67","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","836.10","44.45","","76.54","76.54","76.54","1 through 10","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","both","","","1881.00","1410.75","WELLPOINT [1015]","HB CH WELLPOINT","1465.49","77.91","","273.64","94.28","1367.51","138","836.1","1465.49","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1881.00","1410.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1115.43","59.3","","720.78","230.14","2010.94","427","940.5","1475.64","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1881.00","1410.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1115.43","59.3","","344.45","344.45","344.45","1 through 10","940.5","1475.64","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1881.00","1410.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1475.64","78.45","","1120.13","1120.13","1120.13","1 through 10","940.5","1475.64","percent of total billed charges",""
"SCREW BONE 6.5X45MM COMPRESSX COMPRESSION","SUP-ITM-10138534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1881.00","1410.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1475.64","78.45","","456.17","105.33","1284.66","242","940.5","1475.64","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","AETNA [1001]","HB CH AETNA HMO / PPO","627.89","58.3","","464.71","67.87","1012.10","221","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","627.89","58.3","","293.04","293.04","293.04","11","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","570.81","53","","983.89","983.89","983.89","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","624.66","58","","677.18","677.18","677.18","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","673.13","62.5","","46.58","46.58","46.58","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","786.21","73","","747.15","747.15","747.15","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.73","44.45","","1141.67","481.21","1141.67","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.73","44.45","","76.54","76.54","76.54","1 through 10","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.00","807.75","WELLPOINT [1015]","HB CH WELLPOINT","839.09","77.91","","273.64","94.28","1367.51","138","478.73","839.09","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.00","807.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","638.66","59.3","","720.78","230.14","2010.94","427","538.5","844.91","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.00","807.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","638.66","59.3","","344.45","344.45","344.45","1 through 10","538.5","844.91","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.00","807.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","844.91","78.45","","1120.13","1120.13","1120.13","1 through 10","538.5","844.91","percent of total billed charges",""
"SCREW BONE 6.5X45MM DARCO CANNULATED TI HEADED","SUP-ITM-10132907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.00","807.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","844.91","78.45","","456.17","105.33","1284.66","242","538.5","844.91","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","464.71","67.87","1012.10","221","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","293.04","293.04","293.04","11","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","983.89","983.89","983.89","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.12","58","","677.18","677.18","677.18","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","71.25","62.5","","46.58","46.58","46.58","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","747.15","747.15","747.15","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","1141.67","481.21","1141.67","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","76.54","76.54","76.54","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","273.64","94.28","1367.51","138","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","720.78","230.14","2010.94","427","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.60","59.3","","344.45","344.45","344.45","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","1120.13","1120.13","1120.13","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","456.17","105.33","1284.66","242","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","AETNA [1001]","HB CH AETNA HMO / PPO","1227.80","58.3","","464.71","67.87","1012.10","221","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1227.80","58.3","","293.04","293.04","293.04","11","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1116.18","53","","983.89","983.89","983.89","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1221.48","58","","677.18","677.18","677.18","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1316.25","62.5","","46.58","46.58","46.58","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1537.38","73","","747.15","747.15","747.15","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","936.12","44.45","","1141.67","481.21","1141.67","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","936.12","44.45","","76.54","76.54","76.54","1 through 10","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2106.00","1579.50","WELLPOINT [1015]","HB CH WELLPOINT","1640.78","77.91","","273.64","94.28","1367.51","138","936.12","1640.78","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2106.00","1579.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1248.86","59.3","","720.78","230.14","2010.94","427","1053","1652.16","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2106.00","1579.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1248.86","59.3","","344.45","344.45","344.45","1 through 10","1053","1652.16","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2106.00","1579.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1652.16","78.45","","1120.13","1120.13","1120.13","1 through 10","1053","1652.16","percent of total billed charges",""
"SCREW BONE 6.5X45MM SHORT THREAD CANNULATED LAG","SUP-ITM-10297982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2106.00","1579.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1652.16","78.45","","456.17","105.33","1284.66","242","1053","1652.16","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","1530.90","1160.93","1884.08","89","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","5253.92","5253.92","5253.92","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","66.12","58","","12181.47","12181.47","12181.47","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","71.25","62.5","","1350.68","1350.68","1350.68","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","1910.74","891.94","1910.74","1 through 10","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","1829.79","1561.50","2617.12","88","50.67","88.82","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","1359.46","1201.30","1689.00","61","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","67.60","59.3","","1718.92","1718.92","1718.92","1 through 10","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10120744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","1910.74","1019.06","2344.84","74","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","AETNA [1001]","HB CH AETNA HMO / PPO","311.74","58.3","","464.71","67.87","1012.10","221","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","311.74","58.3","","293.04","293.04","293.04","11","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","283.40","53","","983.89","983.89","983.89","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","310.14","58","","677.18","677.18","677.18","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","334.20","62.5","","46.58","46.58","46.58","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","390.35","73","","747.15","747.15","747.15","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.68","44.45","","1141.67","481.21","1141.67","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.68","44.45","","76.54","76.54","76.54","1 through 10","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","WELLPOINT [1015]","HB CH WELLPOINT","416.60","77.91","","273.64","94.28","1367.51","138","237.68","416.6","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","317.09","59.3","","720.78","230.14","2010.94","427","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","317.09","59.3","","344.45","344.45","344.45","1 through 10","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","419.49","78.45","","1120.13","1120.13","1120.13","1 through 10","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X55MM 16MM THREAD TITANIUM CANNULATED HEXAGONAL SOCKET","SUP-ITM-10039901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","419.49","78.45","","456.17","105.33","1284.66","242","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","AETNA [1001]","HB CH AETNA HMO / PPO","283.76","58.3","","464.71","67.87","1012.10","221","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","283.76","58.3","","293.04","293.04","293.04","11","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","257.96","53","","983.89","983.89","983.89","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.30","58","","677.18","677.18","677.18","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.20","62.5","","46.58","46.58","46.58","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.31","73","","747.15","747.15","747.15","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.35","44.45","","1141.67","481.21","1141.67","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.35","44.45","","76.54","76.54","76.54","1 through 10","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","WELLPOINT [1015]","HB CH WELLPOINT","379.20","77.91","","273.64","94.28","1367.51","138","216.35","379.2","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.62","59.3","","720.78","230.14","2010.94","427","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","288.62","59.3","","344.45","344.45","344.45","1 through 10","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","381.83","78.45","","1120.13","1120.13","1120.13","1 through 10","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.83","78.45","","456.17","105.33","1284.66","242","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","AETNA [1001]","HB CH AETNA HMO / PPO","98.36","58.3","","464.71","67.87","1012.10","221","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","98.36","58.3","","293.04","293.04","293.04","11","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.42","53","","983.89","983.89","983.89","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","97.86","58","","677.18","677.18","677.18","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","105.45","62.5","","46.58","46.58","46.58","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","123.17","73","","747.15","747.15","747.15","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.00","44.45","","1141.67","481.21","1141.67","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.00","44.45","","76.54","76.54","76.54","1 through 10","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","WELLPOINT [1015]","HB CH WELLPOINT","131.45","77.91","","273.64","94.28","1367.51","138","75","131.45","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.05","59.3","","720.78","230.14","2010.94","427","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","100.05","59.3","","344.45","344.45","344.45","1 through 10","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","132.36","78.45","","1120.13","1120.13","1120.13","1 through 10","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","132.36","78.45","","456.17","105.33","1284.66","242","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","AETNA [1001]","HB CH AETNA HMO / PPO","293.80","58.3","","464.71","67.87","1012.10","221","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","293.80","58.3","","293.04","293.04","293.04","11","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","267.09","53","","983.89","983.89","983.89","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","292.29","58","","677.18","677.18","677.18","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","314.96","62.5","","46.58","46.58","46.58","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","367.88","73","","747.15","747.15","747.15","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.00","44.45","","1141.67","481.21","1141.67","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.00","44.45","","76.54","76.54","76.54","1 through 10","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","WELLPOINT [1015]","HB CH WELLPOINT","392.62","77.91","","273.64","94.28","1367.51","138","224","392.62","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","298.84","59.3","","720.78","230.14","2010.94","427","251.97","395.34","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","298.84","59.3","","344.45","344.45","344.45","1 through 10","251.97","395.34","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","395.34","78.45","","1120.13","1120.13","1120.13","1 through 10","251.97","395.34","percent of total billed charges",""
"SCREW BONE 6.5X85MM RECONSTRUCTION HIP TITANIUM LOCKING 30MM THREAD SELF TAPPING BLUNT TIP PARTIAL STARDRIVE","SUP-ITM-10025091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","395.34","78.45","","456.17","105.33","1284.66","242","251.97","395.34","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","AETNA [1001]","HB CH AETNA HMO / PPO","237.86","58.3","","464.71","67.87","1012.10","221","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.86","58.3","","293.04","293.04","293.04","11","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.24","53","","983.89","983.89","983.89","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","236.64","58","","677.18","677.18","677.18","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","255.00","62.5","","46.58","46.58","46.58","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.84","73","","747.15","747.15","747.15","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.36","44.45","","1141.67","481.21","1141.67","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.36","44.45","","76.54","76.54","76.54","1 through 10","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","WELLPOINT [1015]","HB CH WELLPOINT","317.87","77.91","","273.64","94.28","1367.51","138","181.36","317.87","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.94","59.3","","720.78","230.14","2010.94","427","204","320.08","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","241.94","59.3","","344.45","344.45","344.45","1 through 10","204","320.08","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","1120.13","1120.13","1120.13","1 through 10","204","320.08","percent of total billed charges",""
"SCREW BONE 6X1.8MM HAND HEXAGONAL DRIVE 4 EMERGENCY APTUS TITANIUM","SUP-ITM-10051640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","456.17","105.33","1284.66","242","204","320.08","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","AETNA [1001]","HB CH AETNA HMO / PPO","108.02","58.3","","464.71","67.87","1012.10","221","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.02","58.3","","293.04","293.04","293.04","11","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.20","53","","983.89","983.89","983.89","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","107.46","58","","677.18","677.18","677.18","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","115.80","62.5","","46.58","46.58","46.58","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","747.15","747.15","747.15","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","1141.67","481.21","1141.67","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","76.54","76.54","76.54","1 through 10","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","WELLPOINT [1015]","HB CH WELLPOINT","144.35","77.91","","273.64","94.28","1367.51","138","82.36","144.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.87","59.3","","720.78","230.14","2010.94","427","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","109.87","59.3","","344.45","344.45","344.45","1 through 10","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","1120.13","1120.13","1120.13","1 through 10","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","456.17","105.33","1284.66","242","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","464.71","67.87","1012.10","221","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","293.04","293.04","293.04","11","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","983.89","983.89","983.89","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1409.40","58","","677.18","677.18","677.18","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1518.75","62.5","","46.58","46.58","46.58","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","747.15","747.15","747.15","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","1141.67","481.21","1141.67","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","76.54","76.54","76.54","1 through 10","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","273.64","94.28","1367.51","138","1080.14","1893.21","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","720.78","230.14","2010.94","427","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1440.99","59.3","","344.45","344.45","344.45","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1120.13","1120.13","1120.13","1 through 10","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","456.17","105.33","1284.66","242","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","AETNA [1001]","HB CH AETNA HMO / PPO","117.97","58.3","","464.71","67.87","1012.10","221","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.97","58.3","","293.04","293.04","293.04","11","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","107.25","53","","983.89","983.89","983.89","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","117.36","58","","677.18","677.18","677.18","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","126.47","62.5","","46.58","46.58","46.58","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","147.72","73","","747.15","747.15","747.15","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.94","44.45","","1141.67","481.21","1141.67","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.94","44.45","","76.54","76.54","76.54","1 through 10","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.35","151.76","WELLPOINT [1015]","HB CH WELLPOINT","157.65","77.91","","273.64","94.28","1367.51","138","89.94","157.65","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.35","151.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.99","59.3","","720.78","230.14","2010.94","427","101.18","158.74","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.35","151.76","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","119.99","59.3","","344.45","344.45","344.45","1 through 10","101.18","158.74","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.35","151.76","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","158.74","78.45","","1120.13","1120.13","1120.13","1 through 10","101.18","158.74","percent of total billed charges",""
"SCREW BONE 6X70MM CANCELLOUS TITANIUM FULL THREAD","SUP-ITM-10144404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.35","151.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.74","78.45","","456.17","105.33","1284.66","242","101.18","158.74","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","AETNA [1001]","HB CH AETNA HMO / PPO","1077.38","58.3","","464.71","67.87","1012.10","221","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1077.38","58.3","","293.04","293.04","293.04","11","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","979.44","53","","983.89","983.89","983.89","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1071.84","58","","677.18","677.18","677.18","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1155.00","62.5","","46.58","46.58","46.58","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1349.04","73","","747.15","747.15","747.15","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.44","44.45","","1141.67","481.21","1141.67","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.44","44.45","","76.54","76.54","76.54","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","WELLPOINT [1015]","HB CH WELLPOINT","1439.78","77.91","","273.64","94.28","1367.51","138","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1095.86","59.3","","720.78","230.14","2010.94","427","924","1449.76","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1095.86","59.3","","344.45","344.45","344.45","1 through 10","924","1449.76","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1449.76","78.45","","1120.13","1120.13","1120.13","1 through 10","924","1449.76","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10051535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1449.76","78.45","","456.17","105.33","1284.66","242","924","1449.76","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 7 TO 7.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","AETNA [1001]","HB CH AETNA HMO / PPO","400.52","58.3","","464.71","67.87","1012.10","221","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","400.52","58.3","","293.04","293.04","293.04","11","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","364.11","53","","983.89","983.89","983.89","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","398.46","58","","677.18","677.18","677.18","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","429.38","62.5","","46.58","46.58","46.58","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","501.51","73","","747.15","747.15","747.15","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.37","44.45","","1141.67","481.21","1141.67","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.37","44.45","","76.54","76.54","76.54","1 through 10","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","both","","","687.00","515.25","WELLPOINT [1015]","HB CH WELLPOINT","535.24","77.91","","273.64","94.28","1367.51","138","305.37","535.24","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","407.39","59.3","","720.78","230.14","2010.94","427","343.5","538.95","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","407.39","59.3","","344.45","344.45","344.45","1 through 10","343.5","538.95","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","538.95","78.45","","1120.13","1120.13","1120.13","1 through 10","343.5","538.95","percent of total billed charges",""
"SCREW BONE 7 TO 9X30MM TIBIAL FIXATION BIO INTRAFIX BIOCRYL BIOABSORBABLE TAPERED","SUP-ITM-10148902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","687.00","515.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","538.95","78.45","","456.17","105.33","1284.66","242","343.5","538.95","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","464.71","67.87","1012.10","221","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","293.04","293.04","293.04","11","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","983.89","983.89","983.89","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","361.92","58","","677.18","677.18","677.18","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","390.00","62.5","","46.58","46.58","46.58","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","747.15","747.15","747.15","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","1141.67","481.21","1141.67","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","76.54","76.54","76.54","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","273.64","94.28","1367.51","138","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","720.78","230.14","2010.94","427","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","370.03","59.3","","344.45","344.45","344.45","1 through 10","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","1120.13","1120.13","1120.13","1 through 10","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","456.17","105.33","1284.66","242","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","464.71","67.87","1012.10","221","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","293.04","293.04","293.04","11","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","983.89","983.89","983.89","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","361.92","58","","677.18","677.18","677.18","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","390.00","62.5","","46.58","46.58","46.58","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","747.15","747.15","747.15","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","1141.67","481.21","1141.67","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","76.54","76.54","76.54","1 through 10","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","273.64","94.28","1367.51","138","277.37","486.16","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","720.78","230.14","2010.94","427","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","370.03","59.3","","344.45","344.45","344.45","1 through 10","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","1120.13","1120.13","1120.13","1 through 10","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","456.17","105.33","1284.66","242","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","464.71","67.87","1012.10","221","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","293.04","293.04","293.04","11","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","983.89","983.89","983.89","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1456.38","58","","677.18","677.18","677.18","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1569.38","62.5","","46.58","46.58","46.58","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","747.15","747.15","747.15","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","1141.67","481.21","1141.67","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","76.54","76.54","76.54","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","273.64","94.28","1367.51","138","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","720.78","230.14","2010.94","427","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1489.02","59.3","","344.45","344.45","344.45","1 through 10","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.0X40MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10043079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","456.17","105.33","1284.66","242","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","AETNA [1001]","HB CH AETNA HMO / PPO","282.08","58.3","","464.71","67.87","1012.10","221","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","282.08","58.3","","293.04","293.04","293.04","11","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","256.44","53","","983.89","983.89","983.89","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","280.63","58","","677.18","677.18","677.18","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","302.40","62.5","","46.58","46.58","46.58","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","353.20","73","","747.15","747.15","747.15","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.07","44.45","","1141.67","481.21","1141.67","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.07","44.45","","76.54","76.54","76.54","1 through 10","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","WELLPOINT [1015]","HB CH WELLPOINT","376.96","77.91","","273.64","94.28","1367.51","138","215.07","376.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","286.92","59.3","","720.78","230.14","2010.94","427","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","286.92","59.3","","344.45","344.45","344.45","1 through 10","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","379.57","78.45","","1120.13","1120.13","1120.13","1 through 10","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","379.57","78.45","","456.17","105.33","1284.66","242","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","AETNA [1001]","HB CH AETNA HMO / PPO","346.21","58.3","","464.71","67.87","1012.10","221","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.21","58.3","","293.04","293.04","293.04","11","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","314.74","53","","983.89","983.89","983.89","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","344.43","58","","677.18","677.18","677.18","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","371.16","62.5","","46.58","46.58","46.58","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","433.51","73","","747.15","747.15","747.15","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.97","44.45","","1141.67","481.21","1141.67","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.97","44.45","","76.54","76.54","76.54","1 through 10","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","WELLPOINT [1015]","HB CH WELLPOINT","462.67","77.91","","273.64","94.28","1367.51","138","263.97","462.67","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.15","59.3","","720.78","230.14","2010.94","427","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","352.15","59.3","","344.45","344.45","344.45","1 through 10","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","465.88","78.45","","1120.13","1120.13","1120.13","1 through 10","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.88","78.45","","456.17","105.33","1284.66","242","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","AETNA [1001]","HB CH AETNA HMO / PPO","316.45","58.3","","464.71","67.87","1012.10","221","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","316.45","58.3","","293.04","293.04","293.04","11","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","287.68","53","","983.89","983.89","983.89","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","314.82","58","","677.18","677.18","677.18","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","339.24","62.5","","46.58","46.58","46.58","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","396.24","73","","747.15","747.15","747.15","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.27","44.45","","1141.67","481.21","1141.67","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.27","44.45","","76.54","76.54","76.54","1 through 10","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","542.79","407.09","WELLPOINT [1015]","HB CH WELLPOINT","422.89","77.91","","273.64","94.28","1367.51","138","241.27","422.89","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","542.79","407.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","321.87","59.3","","720.78","230.14","2010.94","427","271.4","425.82","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","542.79","407.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","321.87","59.3","","344.45","344.45","344.45","1 through 10","271.4","425.82","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","542.79","407.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","425.82","78.45","","1120.13","1120.13","1120.13","1 through 10","271.4","425.82","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","542.79","407.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","425.82","78.45","","456.17","105.33","1284.66","242","271.4","425.82","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","2190.90","412.50","9264.59","16","333.38","584.33","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","1903.20","1903.20","3826.66","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","2186.25","2186.25","2186.25","32","333.38","584.33","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","5556.60","5556.60","5556.60","1 through 10","333.38","584.33","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","1955.15","885.83","3150.40","26","333.38","584.33","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","831.03","253.22","2394.88","18","375","588.38","percent of total billed charges",""
"SCREW BONE 7.5X35MM SPINE FIREBIRD TITANIUM SELF TAPPING","SUP-ITM-10083470","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","2481.69","1563.74","8149.28","1 through 10","375","588.38","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","2190.90","412.50","9264.59","16","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","1903.20","1903.20","3826.66","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","2186.25","2186.25","2186.25","32","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","5556.60","5556.60","5556.60","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1955.15","885.83","3150.40","26","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","831.03","253.22","2394.88","18","600","941.4","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","2481.69","1563.74","8149.28","1 through 10","600","941.4","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","AETNA [1001]","HB CH AETNA HMO / PPO","367.71","58.3","","464.71","67.87","1012.10","221","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.71","58.3","","293.04","293.04","293.04","11","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","334.28","53","","983.89","983.89","983.89","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","365.82","58","","677.18","677.18","677.18","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","394.20","62.5","","46.58","46.58","46.58","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","460.43","73","","747.15","747.15","747.15","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.36","44.45","","1141.67","481.21","1141.67","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.36","44.45","","76.54","76.54","76.54","1 through 10","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","WELLPOINT [1015]","HB CH WELLPOINT","491.39","77.91","","273.64","94.28","1367.51","138","280.36","491.39","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","374.02","59.3","","720.78","230.14","2010.94","427","315.36","494.8","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","374.02","59.3","","344.45","344.45","344.45","1 through 10","315.36","494.8","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","494.80","78.45","","1120.13","1120.13","1120.13","1 through 10","315.36","494.8","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.80","78.45","","456.17","105.33","1284.66","242","315.36","494.8","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","464.71","67.87","1012.10","221","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","293.04","293.04","293.04","11","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","983.89","983.89","983.89","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","461.10","58","","677.18","677.18","677.18","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","496.88","62.5","","46.58","46.58","46.58","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","747.15","747.15","747.15","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","1141.67","481.21","1141.67","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","76.54","76.54","76.54","1 through 10","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","273.64","94.28","1367.51","138","353.38","619.38","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","720.78","230.14","2010.94","427","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","471.44","59.3","","344.45","344.45","344.45","1 through 10","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","1120.13","1120.13","1120.13","1 through 10","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","456.17","105.33","1284.66","242","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","AETNA [1001]","HB CH AETNA HMO / PPO","251.28","58.3","","464.71","67.87","1012.10","221","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","251.28","58.3","","293.04","293.04","293.04","11","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","228.44","53","","983.89","983.89","983.89","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","249.99","58","","677.18","677.18","677.18","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","269.38","62.5","","46.58","46.58","46.58","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","314.64","73","","747.15","747.15","747.15","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.58","44.45","","1141.67","481.21","1141.67","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.58","44.45","","76.54","76.54","76.54","1 through 10","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","both","","","431.01","323.26","WELLPOINT [1015]","HB CH WELLPOINT","335.80","77.91","","273.64","94.28","1367.51","138","191.58","335.8","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","431.01","323.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","255.59","59.3","","720.78","230.14","2010.94","427","215.51","338.13","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","431.01","323.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","255.59","59.3","","344.45","344.45","344.45","1 through 10","215.51","338.13","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","431.01","323.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","338.13","78.45","","1120.13","1120.13","1120.13","1 through 10","215.51","338.13","percent of total billed charges",""
"SCREW BONE 7X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","431.01","323.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","338.13","78.45","","456.17","105.33","1284.66","242","215.51","338.13","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","2190.90","412.50","9264.59","16","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","1903.20","1903.20","3826.66","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","2186.25","2186.25","2186.25","32","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","5556.60","5556.60","5556.60","1 through 10","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","1955.15","885.83","3150.40","26","533.4","934.92","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","831.03","253.22","2394.88","18","600","941.4","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE MATRIX TITANIUM DUAL CORE DOUBLE LEAD THREAD T25 STARDRIVE RECESS POLYAXIAL","SUP-ITM-10080670","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","2481.69","1563.74","8149.28","1 through 10","600","941.4","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","AETNA [1001]","HB CH AETNA HMO / PPO","1215.56","58.3","","464.71","67.87","1012.10","221","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1215.56","58.3","","293.04","293.04","293.04","11","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1105.05","53","","983.89","983.89","983.89","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1209.30","58","","677.18","677.18","677.18","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1303.13","62.5","","46.58","46.58","46.58","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1522.05","73","","747.15","747.15","747.15","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.78","44.45","","1141.67","481.21","1141.67","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.78","44.45","","76.54","76.54","76.54","1 through 10","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","WELLPOINT [1015]","HB CH WELLPOINT","1624.42","77.91","","273.64","94.28","1367.51","138","926.78","1624.42","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1236.41","59.3","","720.78","230.14","2010.94","427","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1236.41","59.3","","344.45","344.45","344.45","1 through 10","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1635.68","78.45","","1120.13","1120.13","1120.13","1 through 10","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 7X55MM XL COMPRESSION FT","SUP-ITM-10274438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1635.68","78.45","","456.17","105.33","1284.66","242","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","AETNA [1001]","HB CH AETNA HMO / PPO","1077.38","58.3","","464.71","67.87","1012.10","221","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1077.38","58.3","","293.04","293.04","293.04","11","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","979.44","53","","983.89","983.89","983.89","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1071.84","58","","677.18","677.18","677.18","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1155.00","62.5","","46.58","46.58","46.58","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1349.04","73","","747.15","747.15","747.15","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.44","44.45","","1141.67","481.21","1141.67","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.44","44.45","","76.54","76.54","76.54","1 through 10","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","WELLPOINT [1015]","HB CH WELLPOINT","1439.78","77.91","","273.64","94.28","1367.51","138","821.44","1439.78","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1095.86","59.3","","720.78","230.14","2010.94","427","924","1449.76","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1095.86","59.3","","344.45","344.45","344.45","1 through 10","924","1449.76","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1449.76","78.45","","1120.13","1120.13","1120.13","1 through 10","924","1449.76","percent of total billed charges",""
"SCREW BONE 8 TO 8.5MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1449.76","78.45","","456.17","105.33","1284.66","242","924","1449.76","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","AETNA [1001]","HB CH AETNA HMO / PPO","518.68","58.3","","464.71","67.87","1012.10","221","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","518.68","58.3","","293.04","293.04","293.04","11","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","471.53","53","","983.89","983.89","983.89","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","516.01","58","","677.18","677.18","677.18","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","556.05","62.5","","46.58","46.58","46.58","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","649.47","73","","747.15","747.15","747.15","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.46","44.45","","1141.67","481.21","1141.67","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.46","44.45","","76.54","76.54","76.54","1 through 10","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","WELLPOINT [1015]","HB CH WELLPOINT","693.15","77.91","","273.64","94.28","1367.51","138","395.46","693.15","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","527.58","59.3","","720.78","230.14","2010.94","427","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","527.58","59.3","","344.45","344.45","344.45","1 through 10","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","697.95","78.45","","1120.13","1120.13","1120.13","1 through 10","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","697.95","78.45","","456.17","105.33","1284.66","242","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"SCREW BONE 8.0X20MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORK TIP","SUP-ITM-10049362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","464.71","67.87","1012.10","221","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","293.04","293.04","293.04","11","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","983.89","983.89","983.89","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","840.16","58","","677.18","677.18","677.18","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","905.34","62.5","","46.58","46.58","46.58","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","747.15","747.15","747.15","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","1141.67","481.21","1141.67","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","76.54","76.54","76.54","1 through 10","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","273.64","94.28","1367.51","138","643.88","1128.57","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","720.78","230.14","2010.94","427","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","858.99","59.3","","344.45","344.45","344.45","1 through 10","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","1120.13","1120.13","1120.13","1 through 10","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 80MM FENESTRATED AQANIFE TFN ADVANCED","SUP-ITM-10236248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","456.17","105.33","1284.66","242","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","AETNA [1001]","HB CH AETNA HMO / PPO","768.14","58.3","","464.71","67.87","1012.10","221","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","768.14","58.3","","293.04","293.04","293.04","11","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","698.31","53","","983.89","983.89","983.89","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","764.19","58","","677.18","677.18","677.18","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","823.48","62.5","","46.58","46.58","46.58","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","961.83","73","","747.15","747.15","747.15","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.66","44.45","","1141.67","481.21","1141.67","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.66","44.45","","76.54","76.54","76.54","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","WELLPOINT [1015]","HB CH WELLPOINT","1026.52","77.91","","273.64","94.28","1367.51","138","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","781.32","59.3","","720.78","230.14","2010.94","427","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","781.32","59.3","","344.45","344.45","344.45","1 through 10","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1033.63","78.45","","1120.13","1120.13","1120.13","1 through 10","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1033.63","78.45","","456.17","105.33","1284.66","242","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","AETNA [1001]","HB CH AETNA HMO / PPO","447.52","58.3","","464.71","67.87","1012.10","221","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","447.52","58.3","","293.04","293.04","293.04","11","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","406.83","53","","983.89","983.89","983.89","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","445.21","58","","677.18","677.18","677.18","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","479.76","62.5","","46.58","46.58","46.58","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","560.36","73","","747.15","747.15","747.15","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.20","44.45","","1141.67","481.21","1141.67","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.20","44.45","","76.54","76.54","76.54","1 through 10","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","767.61","575.71","WELLPOINT [1015]","HB CH WELLPOINT","598.04","77.91","","273.64","94.28","1367.51","138","341.2","598.04","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","455.19","59.3","","720.78","230.14","2010.94","427","383.81","602.19","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","455.19","59.3","","344.45","344.45","344.45","1 through 10","383.81","602.19","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","602.19","78.45","","1120.13","1120.13","1120.13","1 through 10","383.81","602.19","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","767.61","575.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","602.19","78.45","","456.17","105.33","1284.66","242","383.81","602.19","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","AETNA [1001]","HB CH AETNA HMO / PPO","412.76","58.3","","464.71","67.87","1012.10","221","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","412.76","58.3","","293.04","293.04","293.04","11","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","375.24","53","","983.89","983.89","983.89","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","410.64","58","","677.18","677.18","677.18","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","442.50","62.5","","46.58","46.58","46.58","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","516.84","73","","747.15","747.15","747.15","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","314.71","44.45","","1141.67","481.21","1141.67","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","314.71","44.45","","76.54","76.54","76.54","1 through 10","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","both","","","708.00","531.00","WELLPOINT [1015]","HB CH WELLPOINT","551.60","77.91","","273.64","94.28","1367.51","138","314.71","551.6","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","708.00","531.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","419.84","59.3","","720.78","230.14","2010.94","427","354","555.43","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","708.00","531.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","419.84","59.3","","344.45","344.45","344.45","1 through 10","354","555.43","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","708.00","531.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","555.43","78.45","","1120.13","1120.13","1120.13","1 through 10","354","555.43","percent of total billed charges",""
"SCREW BONE 8X30MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","708.00","531.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","555.43","78.45","","456.17","105.33","1284.66","242","354","555.43","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","464.71","67.87","1012.10","221","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.88","58.3","","293.04","293.04","293.04","11","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","983.89","983.89","983.89","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.50","58","","677.18","677.18","677.18","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.13","62.5","","46.58","46.58","46.58","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","747.15","747.15","747.15","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","1141.67","481.21","1141.67","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","76.54","76.54","76.54","1 through 10","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","273.64","94.28","1367.51","138","500.06","876.49","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","720.78","230.14","2010.94","427","562.5","882.56","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.13","59.3","","344.45","344.45","344.45","1 through 10","562.5","882.56","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","1120.13","1120.13","1120.13","1 through 10","562.5","882.56","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","456.17","105.33","1284.66","242","562.5","882.56","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","464.71","67.87","1012.10","221","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.47","58.3","","293.04","293.04","293.04","11","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","983.89","983.89","983.89","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","495.90","58","","677.18","677.18","677.18","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","534.38","62.5","","46.58","46.58","46.58","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","747.15","747.15","747.15","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","1141.67","481.21","1141.67","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","76.54","76.54","76.54","1 through 10","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","273.64","94.28","1367.51","138","380.05","666.13","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","720.78","230.14","2010.94","427","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","507.02","59.3","","344.45","344.45","344.45","1 through 10","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","1120.13","1120.13","1120.13","1 through 10","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","456.17","105.33","1284.66","242","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","AETNA [1001]","HB CH AETNA HMO / PPO","270.50","58.3","","464.71","67.87","1012.10","221","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","270.50","58.3","","293.04","293.04","293.04","11","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.91","53","","983.89","983.89","983.89","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","269.11","58","","677.18","677.18","677.18","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","289.99","62.5","","46.58","46.58","46.58","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.71","73","","747.15","747.15","747.15","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.24","44.45","","1141.67","481.21","1141.67","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.24","44.45","","76.54","76.54","76.54","1 through 10","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","WELLPOINT [1015]","HB CH WELLPOINT","361.49","77.91","","273.64","94.28","1367.51","138","206.24","361.49","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.14","59.3","","720.78","230.14","2010.94","427","231.99","363.99","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","275.14","59.3","","344.45","344.45","344.45","1 through 10","231.99","363.99","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","363.99","78.45","","1120.13","1120.13","1120.13","1 through 10","231.99","363.99","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.99","78.45","","456.17","105.33","1284.66","242","231.99","363.99","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9 TO 10.0MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION STANDARD","SUP-ITM-10041421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9.0 TO 10MM FEMORAL FIXATION INTRAFIX PEEK SHEATHED ACL RECONSTRUCTION HARD","SUP-ITM-10029197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","464.71","67.87","1012.10","221","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","293.04","293.04","293.04","11","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","983.89","983.89","983.89","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1456.38","58","","677.18","677.18","677.18","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1569.38","62.5","","46.58","46.58","46.58","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","747.15","747.15","747.15","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","1141.67","481.21","1141.67","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","76.54","76.54","76.54","1 through 10","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","273.64","94.28","1367.51","138","1116.14","1956.32","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","720.78","230.14","2010.94","427","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1489.02","59.3","","344.45","344.45","344.45","1 through 10","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 9.0X55MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10179079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","456.17","105.33","1284.66","242","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","AETNA [1001]","HB CH AETNA HMO / PPO","768.14","58.3","","464.71","67.87","1012.10","221","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","768.14","58.3","","293.04","293.04","293.04","11","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","698.31","53","","983.89","983.89","983.89","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","764.19","58","","677.18","677.18","677.18","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","823.48","62.5","","46.58","46.58","46.58","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","961.83","73","","747.15","747.15","747.15","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.66","44.45","","1141.67","481.21","1141.67","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.66","44.45","","76.54","76.54","76.54","1 through 10","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.57","988.18","WELLPOINT [1015]","HB CH WELLPOINT","1026.52","77.91","","273.64","94.28","1367.51","138","585.66","1026.52","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","781.32","59.3","","720.78","230.14","2010.94","427","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","781.32","59.3","","344.45","344.45","344.45","1 through 10","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1033.63","78.45","","1120.13","1120.13","1120.13","1 through 10","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.57","988.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1033.63","78.45","","456.17","105.33","1284.66","242","658.79","1033.63","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","464.71","67.87","1012.10","221","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","293.04","293.04","293.04","11","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","983.89","983.89","983.89","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","391.50","58","","677.18","677.18","677.18","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","421.88","62.5","","46.58","46.58","46.58","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","747.15","747.15","747.15","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","1141.67","481.21","1141.67","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","76.54","76.54","76.54","1 through 10","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","273.64","94.28","1367.51","138","300.04","525.89","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","720.78","230.14","2010.94","427","337.5","529.54","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","400.28","59.3","","344.45","344.45","344.45","1 through 10","337.5","529.54","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","1120.13","1120.13","1120.13","1 through 10","337.5","529.54","percent of total billed charges",""
"SCREW BONE 9X35MM KNEE INTERFERENCE BIOSTEON WEDGE CANNULATED BIOABSORBABLE FULL THREAD UNIVERSAL","SUP-ITM-10036379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","456.17","105.33","1284.66","242","337.5","529.54","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","464.71","67.87","1012.10","221","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","708.35","58.3","","293.04","293.04","293.04","11","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","643.95","53","","983.89","983.89","983.89","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","704.70","58","","677.18","677.18","677.18","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","759.38","62.5","","46.58","46.58","46.58","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","747.15","747.15","747.15","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","1141.67","481.21","1141.67","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","76.54","76.54","76.54","1 through 10","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","273.64","94.28","1367.51","138","540.07","946.61","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","720.78","230.14","2010.94","427","607.5","953.17","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","720.50","59.3","","344.45","344.45","344.45","1 through 10","607.5","953.17","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","1120.13","1120.13","1120.13","1 through 10","607.5","953.17","percent of total billed charges",""
"SCREW BONE G FORCE PEEK INTERFERENCE 86PS0620","SUP-ITM-10057108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","456.17","105.33","1284.66","242","607.5","953.17","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","AETNA [1001]","HB CH AETNA HMO / PPO","431.97","58.3","","464.71","67.87","1012.10","221","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","431.97","58.3","","293.04","293.04","293.04","11","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","392.70","53","","983.89","983.89","983.89","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","429.75","58","","677.18","677.18","677.18","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","463.09","62.5","","46.58","46.58","46.58","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","540.89","73","","747.15","747.15","747.15","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.35","44.45","","1141.67","481.21","1141.67","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.35","44.45","","76.54","76.54","76.54","1 through 10","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.94","555.70","WELLPOINT [1015]","HB CH WELLPOINT","577.27","77.91","","273.64","94.28","1367.51","138","329.35","577.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","439.38","59.3","","720.78","230.14","2010.94","427","370.47","581.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","439.38","59.3","","344.45","344.45","344.45","1 through 10","370.47","581.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","581.27","78.45","","1120.13","1120.13","1120.13","1 through 10","370.47","581.27","percent of total billed charges",""
"SCREW BONE LOCKING ANCHORAGE PLSL3012","SUP-ITM-10051922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.94","555.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","581.27","78.45","","456.17","105.33","1284.66","242","370.47","581.27","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","AETNA [1001]","HB CH AETNA HMO / PPO","160.91","58.3","","464.71","67.87","1012.10","221","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","160.91","58.3","","293.04","293.04","293.04","11","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","146.28","53","","983.89","983.89","983.89","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","160.08","58","","677.18","677.18","677.18","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","172.50","62.5","","46.58","46.58","46.58","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","201.48","73","","747.15","747.15","747.15","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.68","44.45","","1141.67","481.21","1141.67","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.68","44.45","","76.54","76.54","76.54","1 through 10","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","WELLPOINT [1015]","HB CH WELLPOINT","215.03","77.91","","273.64","94.28","1367.51","138","122.68","215.03","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","163.67","59.3","","720.78","230.14","2010.94","427","138","216.52","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","163.67","59.3","","344.45","344.45","344.45","1 through 10","138","216.52","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","216.52","78.45","","1120.13","1120.13","1120.13","1 through 10","138","216.52","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","216.52","78.45","","456.17","105.33","1284.66","242","138","216.52","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","AETNA [1001]","HB CH AETNA HMO / PPO","1547.87","58.3","","464.71","67.87","1012.10","221","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1547.87","58.3","","293.04","293.04","293.04","11","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1407.15","53","","983.89","983.89","983.89","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1539.90","58","","677.18","677.18","677.18","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1659.38","62.5","","46.58","46.58","46.58","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1938.15","73","","747.15","747.15","747.15","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1180.15","44.45","","1141.67","481.21","1141.67","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1180.15","44.45","","76.54","76.54","76.54","1 through 10","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","WELLPOINT [1015]","HB CH WELLPOINT","2068.51","77.91","","273.64","94.28","1367.51","138","1180.15","2068.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1574.42","59.3","","720.78","230.14","2010.94","427","1327.5","2082.85","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1574.42","59.3","","344.45","344.45","344.45","1 through 10","1327.5","2082.85","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2082.85","78.45","","1120.13","1120.13","1120.13","1 through 10","1327.5","2082.85","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840026545T","SUP-ITM-10171270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2082.85","78.45","","456.17","105.33","1284.66","242","1327.5","2082.85","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","464.71","67.87","1012.10","221","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","293.04","293.04","293.04","11","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","983.89","983.89","983.89","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","677.18","677.18","677.18","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","46.58","46.58","46.58","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","747.15","747.15","747.15","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","1141.67","481.21","1141.67","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","76.54","76.54","76.54","1 through 10","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","273.64","94.28","1367.51","138","60.01","105.18","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","720.78","230.14","2010.94","427","67.5","105.91","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","344.45","344.45","344.45","1 through 10","67.5","105.91","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1120.13","1120.13","1120.13","1 through 10","67.5","105.91","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","456.17","105.33","1284.66","242","67.5","105.91","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","AETNA [1001]","HB CH AETNA HMO / PPO","432.00","58.3","","464.71","67.87","1012.10","221","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","432.00","58.3","","293.04","293.04","293.04","11","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","392.73","53","","983.89","983.89","983.89","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","429.78","58","","677.18","677.18","677.18","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","463.13","62.5","","46.58","46.58","46.58","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","540.93","73","","747.15","747.15","747.15","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.37","44.45","","1141.67","481.21","1141.67","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.37","44.45","","76.54","76.54","76.54","1 through 10","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.00","555.75","WELLPOINT [1015]","HB CH WELLPOINT","577.31","77.91","","273.64","94.28","1367.51","138","329.37","577.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.00","555.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","439.41","59.3","","720.78","230.14","2010.94","427","370.5","581.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.00","555.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","439.41","59.3","","344.45","344.45","344.45","1 through 10","370.5","581.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.00","555.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","581.31","78.45","","1120.13","1120.13","1120.13","1 through 10","370.5","581.31","percent of total billed charges",""
"SCREW BONE SZ 2.2 2.4X68MM COUNTERSINK CANNULATED COMPRESSION","SUP-ITM-10286277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.00","555.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","581.31","78.45","","456.17","105.33","1284.66","242","370.5","581.31","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","464.71","67.87","1012.10","221","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4664.00","58.3","","293.04","293.04","293.04","11","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4240.00","53","","983.89","983.89","983.89","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4640.00","58","","677.18","677.18","677.18","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5000.00","62.5","","46.58","46.58","46.58","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","747.15","747.15","747.15","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3556.00","44.45","","1141.67","481.21","1141.67","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3556.00","44.45","","76.54","76.54","76.54","1 through 10","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","273.64","94.28","1367.51","138","3556","6232.8","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","720.78","230.14","2010.94","427","4000","6276","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4744.00","59.3","","344.45","344.45","344.45","1 through 10","4000","6276","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","1120.13","1120.13","1120.13","1 through 10","4000","6276","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","456.17","105.33","1284.66","242","4000","6276","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","464.71","67.87","1012.10","221","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","293.04","293.04","293.04","11","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","983.89","983.89","983.89","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","677.18","677.18","677.18","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","46.58","46.58","46.58","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","747.15","747.15","747.15","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","1141.67","481.21","1141.67","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","76.54","76.54","76.54","1 through 10","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","273.64","94.28","1367.51","138","266.7","467.46","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","720.78","230.14","2010.94","427","300","470.7","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","355.80","59.3","","344.45","344.45","344.45","1 through 10","300","470.7","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1120.13","1120.13","1120.13","1 through 10","300","470.7","percent of total billed charges",""
"SCREW CANNULATED 3.75X32MM FULLY THREADED","SUP-ITM-10115626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","456.17","105.33","1284.66","242","300","470.7","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","AETNA [1001]","HB CH AETNA HMO / PPO","544.88","58.3","","464.71","67.87","1012.10","221","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","544.88","58.3","","293.04","293.04","293.04","11","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","495.35","53","","983.89","983.89","983.89","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","542.08","58","","677.18","677.18","677.18","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","584.14","62.5","","46.58","46.58","46.58","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","682.27","73","","747.15","747.15","747.15","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.44","44.45","","1141.67","481.21","1141.67","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.44","44.45","","76.54","76.54","76.54","1 through 10","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.62","700.96","WELLPOINT [1015]","HB CH WELLPOINT","728.16","77.91","","273.64","94.28","1367.51","138","415.44","728.16","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.62","700.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","554.23","59.3","","720.78","230.14","2010.94","427","467.31","733.21","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.62","700.96","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","554.23","59.3","","344.45","344.45","344.45","1 through 10","467.31","733.21","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.62","700.96","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","733.21","78.45","","1120.13","1120.13","1120.13","1 through 10","467.31","733.21","percent of total billed charges",""
"SCREW IMPLANT 5.0X10.0MM PERIPROSTHETIC LOCKING","SUP-ITM-10151107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.62","700.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","733.21","78.45","","456.17","105.33","1284.66","242","467.31","733.21","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","AETNA [1001]","HB CH AETNA HMO / PPO","974.19","58.3","","464.71","67.87","1012.10","221","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","974.19","58.3","","293.04","293.04","293.04","11","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","885.63","53","","983.89","983.89","983.89","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","969.18","58","","677.18","677.18","677.18","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1044.38","62.5","","46.58","46.58","46.58","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","747.15","747.15","747.15","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","1141.67","481.21","1141.67","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","76.54","76.54","76.54","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","WELLPOINT [1015]","HB CH WELLPOINT","1301.88","77.91","","273.64","94.28","1367.51","138","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","990.90","59.3","","720.78","230.14","2010.94","427","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","990.90","59.3","","344.45","344.45","344.45","1 through 10","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","1120.13","1120.13","1120.13","1 through 10","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 3X20MM PROSTEP STERILE","SUP-ITM-10279097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","456.17","105.33","1284.66","242","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","AETNA [1001]","HB CH AETNA HMO / PPO","974.19","58.3","","464.71","67.87","1012.10","221","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","974.19","58.3","","293.04","293.04","293.04","11","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","885.63","53","","983.89","983.89","983.89","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","969.18","58","","677.18","677.18","677.18","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1044.38","62.5","","46.58","46.58","46.58","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","747.15","747.15","747.15","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","1141.67","481.21","1141.67","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","76.54","76.54","76.54","1 through 10","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","WELLPOINT [1015]","HB CH WELLPOINT","1301.88","77.91","","273.64","94.28","1367.51","138","742.76","1301.88","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","990.90","59.3","","720.78","230.14","2010.94","427","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","990.90","59.3","","344.45","344.45","344.45","1 through 10","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","1120.13","1120.13","1120.13","1 through 10","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","456.17","105.33","1284.66","242","835.5","1310.9","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","AETNA [1001]","HB CH AETNA HMO / PPO","399.21","58.3","","464.71","67.87","1012.10","221","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","399.21","58.3","","293.04","293.04","293.04","11","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.92","53","","983.89","983.89","983.89","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","397.16","58","","677.18","677.18","677.18","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","427.97","62.5","","46.58","46.58","46.58","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.87","73","","747.15","747.15","747.15","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.37","44.45","","1141.67","481.21","1141.67","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.37","44.45","","76.54","76.54","76.54","1 through 10","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","WELLPOINT [1015]","HB CH WELLPOINT","533.49","77.91","","273.64","94.28","1367.51","138","304.37","533.49","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","406.06","59.3","","720.78","230.14","2010.94","427","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","406.06","59.3","","344.45","344.45","344.45","1 through 10","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","537.19","78.45","","1120.13","1120.13","1120.13","1 through 10","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 3X24MM HEADLESS","SUP-ITM-10242592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","537.19","78.45","","456.17","105.33","1284.66","242","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","AETNA [1001]","HB CH AETNA HMO / PPO","336.68","58.3","","464.71","67.87","1012.10","221","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","336.68","58.3","","293.04","293.04","293.04","11","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","306.08","53","","983.89","983.89","983.89","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","334.95","58","","677.18","677.18","677.18","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","360.94","62.5","","46.58","46.58","46.58","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","421.58","73","","747.15","747.15","747.15","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.70","44.45","","1141.67","481.21","1141.67","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.70","44.45","","76.54","76.54","76.54","1 through 10","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB CH WELLPOINT","449.93","77.91","","273.64","94.28","1367.51","138","256.7","449.93","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.46","59.3","","720.78","230.14","2010.94","427","288.75","453.05","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","342.46","59.3","","344.45","344.45","344.45","1 through 10","288.75","453.05","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","453.05","78.45","","1120.13","1120.13","1120.13","1 through 10","288.75","453.05","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 14MM","SUP-ITM-10243314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.05","78.45","","456.17","105.33","1284.66","242","288.75","453.05","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","AETNA [1001]","HB CH AETNA HMO / PPO","692.60","58.3","","464.71","67.87","1012.10","221","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","692.60","58.3","","293.04","293.04","293.04","11","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","629.64","53","","983.89","983.89","983.89","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","689.04","58","","677.18","677.18","677.18","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","742.50","62.5","","46.58","46.58","46.58","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","867.24","73","","747.15","747.15","747.15","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.07","44.45","","1141.67","481.21","1141.67","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.07","44.45","","76.54","76.54","76.54","1 through 10","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","WELLPOINT [1015]","HB CH WELLPOINT","925.57","77.91","","273.64","94.28","1367.51","138","528.07","925.57","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","704.48","59.3","","720.78","230.14","2010.94","427","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","704.48","59.3","","344.45","344.45","344.45","1 through 10","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","931.99","78.45","","1120.13","1120.13","1120.13","1 through 10","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X86MM","SUP-ITM-10242872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","931.99","78.45","","456.17","105.33","1284.66","242","594","931.99","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","AETNA [1001]","HB CH AETNA HMO / PPO","932.51","58.3","","464.71","67.87","1012.10","221","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","932.51","58.3","","293.04","293.04","293.04","11","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","847.74","53","","983.89","983.89","983.89","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","927.72","58","","677.18","677.18","677.18","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","999.69","62.5","","46.58","46.58","46.58","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1167.64","73","","747.15","747.15","747.15","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","710.98","44.45","","1141.67","481.21","1141.67","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","710.98","44.45","","76.54","76.54","76.54","1 through 10","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.51","1199.63","WELLPOINT [1015]","HB CH WELLPOINT","1246.18","77.91","","273.64","94.28","1367.51","138","710.98","1246.18","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.51","1199.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","948.51","59.3","","720.78","230.14","2010.94","427","799.76","1254.82","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.51","1199.63","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","948.51","59.3","","344.45","344.45","344.45","1 through 10","799.76","1254.82","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.51","1199.63","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1254.82","78.45","","1120.13","1120.13","1120.13","1 through 10","799.76","1254.82","percent of total billed charges",""
"SCREW PLATE 112MM 6 HOLE TIBIAL SS DCP HEAD BUTTRESS","SUP-ITM-10005987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.51","1199.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1254.82","78.45","","456.17","105.33","1284.66","242","799.76","1254.82","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","AETNA [1001]","HB CH AETNA HMO / PPO","340.53","58.3","","464.71","67.87","1012.10","221","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","340.53","58.3","","293.04","293.04","293.04","11","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","309.57","53","","983.89","983.89","983.89","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","338.78","58","","677.18","677.18","677.18","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","365.06","62.5","","46.58","46.58","46.58","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","747.15","747.15","747.15","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","1141.67","481.21","1141.67","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","76.54","76.54","76.54","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","WELLPOINT [1015]","HB CH WELLPOINT","455.07","77.91","","273.64","94.28","1367.51","138","259.63","455.07","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.37","59.3","","720.78","230.14","2010.94","427","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","346.37","59.3","","344.45","344.45","344.45","1 through 10","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","1120.13","1120.13","1120.13","1 through 10","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","456.17","105.33","1284.66","242","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","AETNA [1001]","HB CH AETNA HMO / PPO","260.25","58.3","","464.71","67.87","1012.10","221","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.25","58.3","","293.04","293.04","293.04","11","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.59","53","","983.89","983.89","983.89","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","258.91","58","","677.18","677.18","677.18","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","279.00","62.5","","46.58","46.58","46.58","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","747.15","747.15","747.15","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","1141.67","481.21","1141.67","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","76.54","76.54","76.54","1 through 10","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","WELLPOINT [1015]","HB CH WELLPOINT","347.79","77.91","","273.64","94.28","1367.51","138","198.42","347.79","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.72","59.3","","720.78","230.14","2010.94","427","223.2","350.2","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","264.72","59.3","","344.45","344.45","344.45","1 through 10","223.2","350.2","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","1120.13","1120.13","1120.13","1 through 10","223.2","350.2","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","456.17","105.33","1284.66","242","223.2","350.2","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1530.90","1160.93","1884.08","89","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","5253.92","5253.92","5253.92","1 through 10","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","812.58","58","","12181.47","12181.47","12181.47","1 through 10","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","875.63","62.5","","1350.68","1350.68","1350.68","1 through 10","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.74","44.45","","1910.74","891.94","1910.74","1 through 10","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","1829.79","1561.50","2617.12","88","622.74","1091.52","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1359.46","1201.30","1689.00","61","700.5","1099.08","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","830.79","59.3","","1718.92","1718.92","1718.92","1 through 10","700.5","1099.08","percent of total billed charges",""
"SCREW POSTERIOR 15X5MM SIZE 4 WEDGE FEMORAL KNEE L REVISION LEGION","SUP-ITM-10121445","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","1910.74","1019.06","2344.84","74","700.5","1099.08","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","AETNA [1001]","HB CH AETNA HMO / PPO","293.80","58.3","","464.71","67.87","1012.10","221","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","293.80","58.3","","293.04","293.04","293.04","11","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","267.09","53","","983.89","983.89","983.89","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","292.29","58","","677.18","677.18","677.18","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","314.96","62.5","","46.58","46.58","46.58","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","367.88","73","","747.15","747.15","747.15","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.00","44.45","","1141.67","481.21","1141.67","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.00","44.45","","76.54","76.54","76.54","1 through 10","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","both","","","503.94","377.95","WELLPOINT [1015]","HB CH WELLPOINT","392.62","77.91","","273.64","94.28","1367.51","138","224","392.62","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","298.84","59.3","","720.78","230.14","2010.94","427","251.97","395.34","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","298.84","59.3","","344.45","344.45","344.45","1 through 10","251.97","395.34","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","395.34","78.45","","1120.13","1120.13","1120.13","1 through 10","251.97","395.34","percent of total billed charges",""
"SCREW RECONSTRUCTION 30MM 6.5X90 HIP TITANIUM LOCKING SELF TAPPING BLUNT PARTIAL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","503.94","377.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","395.34","78.45","","456.17","105.33","1284.66","242","251.97","395.34","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","AETNA [1001]","HB CH AETNA HMO / PPO","379.04","58.3","","464.71","67.87","1012.10","221","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.04","58.3","","293.04","293.04","293.04","11","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","344.58","53","","983.89","983.89","983.89","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","377.09","58","","677.18","677.18","677.18","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","406.35","62.5","","46.58","46.58","46.58","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","474.62","73","","747.15","747.15","747.15","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.00","44.45","","1141.67","481.21","1141.67","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.00","44.45","","76.54","76.54","76.54","1 through 10","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","650.16","487.62","WELLPOINT [1015]","HB CH WELLPOINT","506.54","77.91","","273.64","94.28","1367.51","138","289","506.54","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","650.16","487.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","385.54","59.3","","720.78","230.14","2010.94","427","325.08","510.05","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","650.16","487.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","385.54","59.3","","344.45","344.45","344.45","1 through 10","325.08","510.05","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","650.16","487.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","510.05","78.45","","1120.13","1120.13","1120.13","1 through 10","325.08","510.05","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","650.16","487.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.05","78.45","","456.17","105.33","1284.66","242","325.08","510.05","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","AETNA [1001]","HB CH AETNA HMO / PPO","4290.88","58.3","","464.71","67.87","1012.10","221","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4290.88","58.3","","293.04","293.04","293.04","11","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3900.80","53","","983.89","983.89","983.89","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4268.80","58","","677.18","677.18","677.18","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4600.00","62.5","","46.58","46.58","46.58","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5372.80","73","","747.15","747.15","747.15","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3271.52","44.45","","1141.67","481.21","1141.67","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3271.52","44.45","","76.54","76.54","76.54","1 through 10","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","both","","","7360.00","5520.00","WELLPOINT [1015]","HB CH WELLPOINT","5734.18","77.91","","273.64","94.28","1367.51","138","3271.52","5734.18","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7360.00","5520.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4364.48","59.3","","720.78","230.14","2010.94","427","3680","5773.92","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7360.00","5520.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4364.48","59.3","","344.45","344.45","344.45","1 through 10","3680","5773.92","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7360.00","5520.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","5773.92","78.45","","1120.13","1120.13","1120.13","1 through 10","3680","5773.92","percent of total billed charges",""
"SCREW SI 11MMX55MM FIREBIRD","SUP-ITM-10319035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7360.00","5520.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5773.92","78.45","","456.17","105.33","1284.66","242","3680","5773.92","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","2190.90","412.50","9264.59","16","666.75","1168.65","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","1903.20","1903.20","3826.66","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","2186.25","2186.25","2186.25","32","666.75","1168.65","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","5556.60","5556.60","5556.60","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","1955.15","885.83","3150.40","26","666.75","1168.65","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","831.03","253.22","2394.88","18","750","1176.75","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2481.69","1563.74","8149.28","1 through 10","750","1176.75","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","464.71","67.87","1012.10","221","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","857.01","58.3","","293.04","293.04","293.04","11","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.10","53","","983.89","983.89","983.89","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","852.60","58","","677.18","677.18","677.18","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","918.75","62.5","","46.58","46.58","46.58","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","747.15","747.15","747.15","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","1141.67","481.21","1141.67","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","76.54","76.54","76.54","1 through 10","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","273.64","94.28","1367.51","138","653.42","1145.28","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","720.78","230.14","2010.94","427","735","1153.22","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","871.71","59.3","","344.45","344.45","344.45","1 through 10","735","1153.22","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","1120.13","1120.13","1120.13","1 through 10","735","1153.22","percent of total billed charges",""
"SCREW SPINAL 4.5X45MM POLYAXIAL VITALITY","SUP-ITM-10247372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","456.17","105.33","1284.66","242","735","1153.22","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","464.71","67.87","1012.10","221","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.63","58.3","","293.04","293.04","293.04","11","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.75","53","","983.89","983.89","983.89","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","217.50","58","","677.18","677.18","677.18","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","234.38","62.5","","46.58","46.58","46.58","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","747.15","747.15","747.15","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","1141.67","481.21","1141.67","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","76.54","76.54","76.54","1 through 10","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","WELLPOINT [1015]","HB CH WELLPOINT","292.16","77.91","","273.64","94.28","1367.51","138","166.69","292.16","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","720.78","230.14","2010.94","427","187.5","294.19","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","222.38","59.3","","344.45","344.45","344.45","1 through 10","187.5","294.19","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","1120.13","1120.13","1120.13","1 through 10","187.5","294.19","percent of total billed charges",""
"SCREW SPINAL 5.5X40MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","456.17","105.33","1284.66","242","187.5","294.19","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","AETNA [1001]","HB CH AETNA HMO / PPO","155.66","58.3","","464.71","67.87","1012.10","221","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","155.66","58.3","","293.04","293.04","293.04","11","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.51","53","","983.89","983.89","983.89","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","154.86","58","","677.18","677.18","677.18","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","166.88","62.5","","46.58","46.58","46.58","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","194.91","73","","747.15","747.15","747.15","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","1141.67","481.21","1141.67","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.68","44.45","","76.54","76.54","76.54","1 through 10","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.00","200.25","WELLPOINT [1015]","HB CH WELLPOINT","208.02","77.91","","273.64","94.28","1367.51","138","118.68","208.02","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.33","59.3","","720.78","230.14","2010.94","427","133.5","209.46","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","158.33","59.3","","344.45","344.45","344.45","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","1120.13","1120.13","1120.13","1 through 10","133.5","209.46","percent of total billed charges",""
"SCREW SPINAL 6.5MMX35MM POST ARTHROSCOPY CANCELLOUS ARTHREX","SUP-ITM-10027302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","209.46","78.45","","456.17","105.33","1284.66","242","133.5","209.46","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","2190.90","412.50","9264.59","16","846.77","1484.19","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1104.90","58","","1903.20","1903.20","3826.66","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1190.63","62.5","","2186.25","2186.25","2186.25","32","846.77","1484.19","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","5556.60","5556.60","5556.60","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","1955.15","885.83","3150.40","26","846.77","1484.19","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","831.03","253.22","2394.88","18","952.5","1494.47","percent of total billed charges",""
"SCREW SPINAL 7.5X45MM PATHFINDER CANNULATED POLYAXIAL","SUP-ITM-10108502","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","2481.69","1563.74","8149.28","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","AETNA [1001]","HB CH AETNA HMO / PPO","122.43","58.3","","464.71","67.87","1012.10","221","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","122.43","58.3","","293.04","293.04","293.04","11","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","111.30","53","","983.89","983.89","983.89","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","121.80","58","","677.18","677.18","677.18","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","131.25","62.5","","46.58","46.58","46.58","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","747.15","747.15","747.15","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","1141.67","481.21","1141.67","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","76.54","76.54","76.54","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB CH WELLPOINT","163.61","77.91","","273.64","94.28","1367.51","138","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.53","59.3","","720.78","230.14","2010.94","427","105","164.75","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","124.53","59.3","","344.45","344.45","344.45","1 through 10","105","164.75","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","1120.13","1120.13","1120.13","1 through 10","105","164.75","percent of total billed charges",""
"SCREW SPINE 2.7X5MM NEWBRIDGE LATERAL","SUP-ITM-10109710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","456.17","105.33","1284.66","242","105","164.75","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","AETNA [1001]","HB CH AETNA HMO / PPO","207.26","58.3","","464.71","67.87","1012.10","221","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","207.26","58.3","","293.04","293.04","293.04","11","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","188.42","53","","983.89","983.89","983.89","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","206.19","58","","677.18","677.18","677.18","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","222.19","62.5","","46.58","46.58","46.58","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","259.52","73","","747.15","747.15","747.15","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.02","44.45","","1141.67","481.21","1141.67","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.02","44.45","","76.54","76.54","76.54","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","WELLPOINT [1015]","HB CH WELLPOINT","276.97","77.91","","273.64","94.28","1367.51","138","158.02","276.97","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.81","59.3","","720.78","230.14","2010.94","427","177.75","278.89","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","210.81","59.3","","344.45","344.45","344.45","1 through 10","177.75","278.89","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","278.89","78.45","","1120.13","1120.13","1120.13","1 through 10","177.75","278.89","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.89","78.45","","456.17","105.33","1284.66","242","177.75","278.89","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","AETNA [1001]","HB CH AETNA HMO / PPO","122.43","58.3","","2190.90","412.50","9264.59","16","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","121.80","58","","1903.20","1903.20","3826.66","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","131.25","62.5","","2186.25","2186.25","2186.25","32","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","5556.60","5556.60","5556.60","1 through 10","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB CH WELLPOINT","163.61","77.91","","1955.15","885.83","3150.40","26","93.35","163.61","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.53","59.3","","831.03","253.22","2394.88","18","105","164.75","percent of total billed charges",""
"SCREW SPINE 2X6MM NEWBRIDGE LATERAL","SUP-ITM-10017702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","2481.69","1563.74","8149.28","1 through 10","105","164.75","percent of total billed charges",""
"SCREW SPINE 3.5X14MM SELF-DRILLING CERVICAL","SUP-ITM-10244032","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","5530.54","5530.54","5530.54","1 through 10","247.5","388.33","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","AETNA [1001]","HB CH AETNA HMO / PPO","340.53","58.3","","464.71","67.87","1012.10","221","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","340.53","58.3","","293.04","293.04","293.04","11","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","309.57","53","","983.89","983.89","983.89","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","338.78","58","","677.18","677.18","677.18","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","365.06","62.5","","46.58","46.58","46.58","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","747.15","747.15","747.15","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","1141.67","481.21","1141.67","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","76.54","76.54","76.54","1 through 10","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","WELLPOINT [1015]","HB CH WELLPOINT","455.07","77.91","","273.64","94.28","1367.51","138","259.63","455.07","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.37","59.3","","720.78","230.14","2010.94","427","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","346.37","59.3","","344.45","344.45","344.45","1 through 10","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","1120.13","1120.13","1120.13","1 through 10","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","456.17","105.33","1284.66","242","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","464.71","67.87","1012.10","221","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","293.04","293.04","293.04","11","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","983.89","983.89","983.89","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","677.18","677.18","677.18","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","46.58","46.58","46.58","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","747.15","747.15","747.15","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1141.67","481.21","1141.67","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","76.54","76.54","76.54","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","273.64","94.28","1367.51","138","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","720.78","230.14","2010.94","427","750","1176.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","344.45","344.45","344.45","1 through 10","750","1176.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1120.13","1120.13","1120.13","1 through 10","750","1176.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","456.17","105.33","1284.66","242","750","1176.75","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","464.71","67.87","1012.10","221","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.61","58.3","","293.04","293.04","293.04","11","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.55","53","","983.89","983.89","983.89","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","252.30","58","","677.18","677.18","677.18","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","271.88","62.5","","46.58","46.58","46.58","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","747.15","747.15","747.15","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","1141.67","481.21","1141.67","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","76.54","76.54","76.54","1 through 10","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","273.64","94.28","1367.51","138","193.36","338.91","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","720.78","230.14","2010.94","427","217.5","341.26","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","257.96","59.3","","344.45","344.45","344.45","1 through 10","217.5","341.26","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","1120.13","1120.13","1120.13","1 through 10","217.5","341.26","percent of total billed charges",""
"SCREW SPINE 35MM LATERAL OFFSET MONOAXIAL","SUP-ITM-10183008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","456.17","105.33","1284.66","242","217.5","341.26","percent of total billed charges",""
"SCREW SPINE 3X14MM CERVICAL PK/2EA","SUP-ITM-10155855","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.77","59.3","","5530.54","5530.54","5530.54","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW SPINE 3X16MM CERVICAL PK/2EA","SUP-ITM-10155856","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","247.50","185.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.77","59.3","","5530.54","5530.54","5530.54","1 through 10","123.75","194.16","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","2190.90","412.50","9264.59","16","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","1903.20","1903.20","3826.66","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","2186.25","2186.25","2186.25","32","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","5556.60","5556.60","5556.60","1 through 10","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","1955.15","885.83","3150.40","26","666.75","1168.65","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","831.03","253.22","2394.88","18","750","1176.75","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MULTIAXIAL 69-3525","SUP-ITM-10182563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2481.69","1563.74","8149.28","1 through 10","750","1176.75","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","AETNA [1001]","HB CH AETNA HMO / PPO","1537.37","58.3","","464.71","67.87","1012.10","221","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1537.37","58.3","","293.04","293.04","293.04","11","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1397.61","53","","983.89","983.89","983.89","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1529.46","58","","677.18","677.18","677.18","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1648.13","62.5","","46.58","46.58","46.58","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1925.01","73","","747.15","747.15","747.15","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.15","44.45","","1141.67","481.21","1141.67","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.15","44.45","","76.54","76.54","76.54","1 through 10","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","WELLPOINT [1015]","HB CH WELLPOINT","2054.49","77.91","","273.64","94.28","1367.51","138","1172.15","2054.49","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1563.74","59.3","","720.78","230.14","2010.94","427","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1563.74","59.3","","344.45","344.45","344.45","1 through 10","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2068.73","78.45","","1120.13","1120.13","1120.13","1 through 10","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4.5X26MM POLYAXIAL 4.0 CFX","SUP-ITM-10243811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2068.73","78.45","","456.17","105.33","1284.66","242","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4X14MM SELF TAPPING POLYAXIAL","SUP-ITM-10175783","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","5530.54","5530.54","5530.54","1 through 10","165","258.89","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","464.71","67.87","1012.10","221","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1110.62","58.3","","293.04","293.04","293.04","11","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1009.65","53","","983.89","983.89","983.89","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1104.90","58","","677.18","677.18","677.18","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1190.63","62.5","","46.58","46.58","46.58","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","747.15","747.15","747.15","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","1141.67","481.21","1141.67","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","76.54","76.54","76.54","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","273.64","94.28","1367.51","138","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","720.78","230.14","2010.94","427","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1129.67","59.3","","344.45","344.45","344.45","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","1120.13","1120.13","1120.13","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE MAS 2C POLY RED","SUP-ITM-10229058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","456.17","105.33","1284.66","242","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","AETNA [1001]","HB CH AETNA HMO / PPO","848.27","58.3","","464.71","67.87","1012.10","221","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","848.27","58.3","","293.04","293.04","293.04","11","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.15","53","","983.89","983.89","983.89","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","843.90","58","","677.18","677.18","677.18","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","909.38","62.5","","46.58","46.58","46.58","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","747.15","747.15","747.15","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","1141.67","481.21","1141.67","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","76.54","76.54","76.54","1 through 10","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","WELLPOINT [1015]","HB CH WELLPOINT","1133.59","77.91","","273.64","94.28","1367.51","138","646.75","1133.59","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.82","59.3","","720.78","230.14","2010.94","427","727.5","1141.45","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","862.82","59.3","","344.45","344.45","344.45","1 through 10","727.5","1141.45","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","1120.13","1120.13","1120.13","1 through 10","727.5","1141.45","percent of total billed charges",""
"SCREW SPINE 5/5.5MM RELINE CONNECTING INLINE","SUP-ITM-10170397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","456.17","105.33","1284.66","242","727.5","1141.45","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","AETNA [1001]","HB CH AETNA HMO / PPO","773.06","58.3","","464.71","67.87","1012.10","221","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","773.06","58.3","","293.04","293.04","293.04","11","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","702.78","53","","983.89","983.89","983.89","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","769.08","58","","677.18","677.18","677.18","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","828.75","62.5","","46.58","46.58","46.58","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","967.98","73","","747.15","747.15","747.15","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","589.41","44.45","","1141.67","481.21","1141.67","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","589.41","44.45","","76.54","76.54","76.54","1 through 10","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","WELLPOINT [1015]","HB CH WELLPOINT","1033.09","77.91","","273.64","94.28","1367.51","138","589.41","1033.09","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","786.32","59.3","","720.78","230.14","2010.94","427","663","1040.25","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","786.32","59.3","","344.45","344.45","344.45","1 through 10","663","1040.25","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1040.25","78.45","","1120.13","1120.13","1120.13","1 through 10","663","1040.25","percent of total billed charges",""
"SCREW SPINE 5X45MM RELINE O TRACTION","SUP-ITM-10170469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1040.25","78.45","","456.17","105.33","1284.66","242","663","1040.25","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","2190.90","412.50","9264.59","16","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1104.90","58","","1903.20","1903.20","3826.66","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1190.63","62.5","","2186.25","2186.25","2186.25","32","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","5556.60","5556.60","5556.60","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","1955.15","885.83","3150.40","26","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","831.03","253.22","2394.88","18","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X40MM CANNULATED LONG BLADE","SUP-ITM-10124697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","2481.69","1563.74","8149.28","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","464.71","67.87","1012.10","221","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","293.04","293.04","293.04","11","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","983.89","983.89","983.89","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","677.18","677.18","677.18","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","46.58","46.58","46.58","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","747.15","747.15","747.15","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1141.67","481.21","1141.67","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","76.54","76.54","76.54","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","273.64","94.28","1367.51","138","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","720.78","230.14","2010.94","427","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","344.45","344.45","344.45","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","456.17","105.33","1284.66","242","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","464.71","67.87","1012.10","221","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","293.04","293.04","293.04","11","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","983.89","983.89","983.89","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","677.18","677.18","677.18","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","46.58","46.58","46.58","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","747.15","747.15","747.15","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1141.67","481.21","1141.67","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","76.54","76.54","76.54","1 through 10","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","273.64","94.28","1367.51","138","1233.49","2162","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","720.78","230.14","2010.94","427","1387.5","2176.99","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1645.58","59.3","","344.45","344.45","344.45","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE 2FS POLYAXIAL","SUP-ITM-10229323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","456.17","105.33","1284.66","242","1387.5","2176.99","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","464.71","67.87","1012.10","221","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1110.62","58.3","","293.04","293.04","293.04","11","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1009.65","53","","983.89","983.89","983.89","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1104.90","58","","677.18","677.18","677.18","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1190.63","62.5","","46.58","46.58","46.58","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","747.15","747.15","747.15","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","1141.67","481.21","1141.67","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","76.54","76.54","76.54","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","273.64","94.28","1367.51","138","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","720.78","230.14","2010.94","427","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1129.67","59.3","","344.45","344.45","344.45","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","1120.13","1120.13","1120.13","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","456.17","105.33","1284.66","242","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","464.71","67.87","1012.10","221","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1110.62","58.3","","293.04","293.04","293.04","11","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1009.65","53","","983.89","983.89","983.89","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1104.90","58","","677.18","677.18","677.18","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1190.63","62.5","","46.58","46.58","46.58","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","747.15","747.15","747.15","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","1141.67","481.21","1141.67","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","76.54","76.54","76.54","1 through 10","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","273.64","94.28","1367.51","138","846.77","1484.19","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","720.78","230.14","2010.94","427","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1129.67","59.3","","344.45","344.45","344.45","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","1120.13","1120.13","1120.13","1 through 10","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7.5X50MM LONGITUDE CANNULATED","SUP-ITM-10136651","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","456.17","105.33","1284.66","242","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","464.71","67.87","1012.10","221","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","293.04","293.04","293.04","11","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","983.89","983.89","983.89","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","677.18","677.18","677.18","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","46.58","46.58","46.58","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","747.15","747.15","747.15","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1141.67","481.21","1141.67","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","76.54","76.54","76.54","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","273.64","94.28","1367.51","138","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","720.78","230.14","2010.94","427","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","344.45","344.45","344.45","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 7.5X55MM RELINE MAS TRACTION POLY","SUP-ITM-10229379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","456.17","105.33","1284.66","242","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","464.71","67.87","1012.10","221","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","293.04","293.04","293.04","11","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","983.89","983.89","983.89","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","677.18","677.18","677.18","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","46.58","46.58","46.58","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","747.15","747.15","747.15","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1141.67","481.21","1141.67","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","76.54","76.54","76.54","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","273.64","94.28","1367.51","138","1066.8","1869.84","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","720.78","230.14","2010.94","427","1200","1882.8","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","344.45","344.45","344.45","1 through 10","1200","1882.8","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1120.13","1120.13","1120.13","1 through 10","1200","1882.8","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","456.17","105.33","1284.66","242","1200","1882.8","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","464.71","67.87","1012.10","221","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","293.04","293.04","293.04","11","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","983.89","983.89","983.89","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","677.18","677.18","677.18","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","46.58","46.58","46.58","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","747.15","747.15","747.15","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1141.67","481.21","1141.67","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","76.54","76.54","76.54","1 through 10","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","273.64","94.28","1367.51","138","933.45","1636.11","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","720.78","230.14","2010.94","427","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","344.45","344.45","344.45","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1120.13","1120.13","1120.13","1 through 10","1050","1647.45","percent of total billed charges",""
"SCREW SPINE 8.5X50MM RELINE MAS TRACTION POLY","SUP-ITM-10229370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","456.17","105.33","1284.66","242","1050","1647.45","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","AETNA [1001]","HB CH AETNA HMO / PPO","207.26","58.3","","464.71","67.87","1012.10","221","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","207.26","58.3","","293.04","293.04","293.04","11","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","188.42","53","","983.89","983.89","983.89","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","206.19","58","","677.18","677.18","677.18","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","222.19","62.5","","46.58","46.58","46.58","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","259.52","73","","747.15","747.15","747.15","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.02","44.45","","1141.67","481.21","1141.67","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.02","44.45","","76.54","76.54","76.54","1 through 10","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.50","266.62","WELLPOINT [1015]","HB CH WELLPOINT","276.97","77.91","","273.64","94.28","1367.51","138","158.02","276.97","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.81","59.3","","720.78","230.14","2010.94","427","177.75","278.89","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","210.81","59.3","","344.45","344.45","344.45","1 through 10","177.75","278.89","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","278.89","78.45","","1120.13","1120.13","1120.13","1 through 10","177.75","278.89","percent of total billed charges",""
"SCREW SURGICAL 20MM SYNFIX EVOLUTION PK/2EA","SUP-ITM-10192252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.50","266.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.89","78.45","","456.17","105.33","1284.66","242","177.75","278.89","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","AETNA [1001]","HB CH AETNA HMO / PPO","395.27","58.3","","464.71","67.87","1012.10","221","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","395.27","58.3","","293.04","293.04","293.04","11","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","359.34","53","","983.89","983.89","983.89","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","393.24","58","","677.18","677.18","677.18","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","423.75","62.5","","46.58","46.58","46.58","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","494.94","73","","747.15","747.15","747.15","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.37","44.45","","1141.67","481.21","1141.67","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.37","44.45","","76.54","76.54","76.54","1 through 10","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","both","","","678.00","508.50","WELLPOINT [1015]","HB CH WELLPOINT","528.23","77.91","","273.64","94.28","1367.51","138","301.37","528.23","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","678.00","508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","402.05","59.3","","720.78","230.14","2010.94","427","339","531.89","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","402.05","59.3","","344.45","344.45","344.45","1 through 10","339","531.89","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","531.89","78.45","","1120.13","1120.13","1120.13","1 through 10","339","531.89","percent of total billed charges",""
"SCREW SURGICAL 44MM LATARJET","SUP-ITM-10194610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","531.89","78.45","","456.17","105.33","1284.66","242","339","531.89","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","464.71","67.87","1012.10","221","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","293.04","293.04","293.04","11","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","983.89","983.89","983.89","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","182.70","58","","677.18","677.18","677.18","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","196.88","62.5","","46.58","46.58","46.58","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","747.15","747.15","747.15","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","1141.67","481.21","1141.67","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","76.54","76.54","76.54","1 through 10","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","273.64","94.28","1367.51","138","140.02","245.42","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","720.78","230.14","2010.94","427","157.5","247.12","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","186.80","59.3","","344.45","344.45","344.45","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","1120.13","1120.13","1120.13","1 through 10","157.5","247.12","percent of total billed charges",""
"SCREW VOLAR 32MM PEG THREADED","SUP-ITM-10100518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","456.17","105.33","1284.66","242","157.5","247.12","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2034.00","1525.50","AETNA [1001]","HB CH AETNA HMO / PPO","1185.82","58.3","","2190.90","412.50","9264.59","16","904.11","1584.69","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2034.00","1525.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1179.72","58","","1903.20","1903.20","3826.66","1 through 10","904.11","1584.69","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2034.00","1525.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1271.25","62.5","","2186.25","2186.25","2186.25","32","904.11","1584.69","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2034.00","1525.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1484.82","73","","5556.60","5556.60","5556.60","1 through 10","904.11","1584.69","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2034.00","1525.50","WELLPOINT [1015]","HB CH WELLPOINT","1584.69","77.91","","1955.15","885.83","3150.40","26","904.11","1584.69","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2034.00","1525.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1206.16","59.3","","831.03","253.22","2394.88","18","1017","1595.67","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2034.00","1525.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1595.67","78.45","","2481.69","1563.74","8149.28","1 through 10","1017","1595.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0300","RC","","","","inpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","23.30","70.6","","14.58","14.58","14.58","1 through 10","18.48","23.3","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","300","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","24.09","73","","23.36","23.36","23.36","1 through 10","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","17.49","53","","31.27","31.27","31.27","1 through 10","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.09","73","","18.14","2.43","32.00","1 through 10","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","TRICARE [160005]","HB NWH TRICARE","31.35","95","","3.25","3.09","3.25","16","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.67","44.45","","24.60","14.58","24.60","12","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.67","44.45","","14.58","14.58","14.58","1 through 10","2.65","31.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.75","24.08","342","2.8","25.89","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","24.60","24.60","1 through 10","2.8","25.89","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","14.58","24.60","317","2.8","25.89","percent of total billed charges",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","53885.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47156.29","","Standard inlier is a Case rate ($47,156.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,693.64) for the length of stay and the standard reimbursement.","47156.29","47156.29","47156.29","1 through 10","5318.86","95052.09","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","53885.61","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8645.3808","","Fee schedule rate ($57,607.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8645.3808","57607.86","57607.86","1 through 10","5318.86","95052.09","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","53885.61","","MASSHEALTH [3001]","HB NWH MEDICAID","25946.56","","Case rate ($27,953.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $70,383.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28025.21","28025.21","28025.21","1 through 10","5318.86","95052.09","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","53885.61","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","25946.56","","Case rate ($27,953.32). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $70,383.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","64942.19","64942.19","64942.19","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","29065.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19293.31","","Standard inlier is a Case rate ($19,293.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,440, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,738.76) for the length of stay and the standard reimbursement.","18418.17","18418.17","18418.17","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","29065.63","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20724.86","","Standard inlier is a Case rate ($20,724.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,440, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,941.81) for the length of stay and the standard reimbursement.","20724.85","20724.85","20724.85","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","29065.63","","MASSHEALTH [3001]","HB NWH MEDICAID","9788.93","","Case rate ($10,546.03). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,976.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10573.15","10573.15","10573.15","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","29065.63","","MASSHEALTH ALTERNATE [3003]","HB NWH MEDICAID","9788.93","","Case rate ($10,546.03). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,976.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1302.56","1302.56","1302.56","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","29065.63","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9788.93","","Case rate ($10,546.03). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $52,976.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13216.44","13216.44","13216.44","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","11079.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12471.78","","Standard inlier is a Case rate ($12,471.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,559, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,770.32) for the length of stay and the standard reimbursement.","12471.78","12471.78","12471.78","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","11079.70","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8645.3808","","Fee schedule rate ($8,645.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8645.3808","8312.26","8312.26","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","11079.70","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","5318.86","","Case rate ($5,730.23). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,160.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7181.20","7181.20","7181.20","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15905.74","","Standard inlier is a Case rate ($15,905.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,257.75) for the length of stay and the standard reimbursement.","15185.76","15185.76","15905.73","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9077.6056","","Fee schedule rate ($18,719.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9077.6056","11267.00","11267.00","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","MASSHEALTH [3001]","HB NWH MEDICAID","6158.50","","Case rate ($6,634.81). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,064.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6651.87","6651.87","6651.87","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10420.82","","Fee schedule rate ($10,420.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7825.03","7825.03","7825.03","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","10941.39","","Fee schedule rate ($10,941.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8215.93","8215.93","8215.93","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","22211.46","","Fee schedule rate ($22,211.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16678.67","16678.67","16678.67","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","9509.8304","","Fee schedule rate ($19,610.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9509.8304","11348.25","11348.25","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","21493.44","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6158.50","","Case rate ($6,634.81). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,064.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1897.17","907.45","6651.87","1 through 10","5318.86","95052.09","case rate",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","41994.60","31495.95","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","17283.70","","Case rate ($16,780.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,380.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,224.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,497.96. The transfer operating threshold is the transfer adjustment factor * $17,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,282.33. The transfer capital threshold is the transfer adjustment factor * $1,282.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","84975.91","84975.91","84975.91","1 through 10","16444.68","19632.6317","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","41994.60","31495.95","MEDICARE [2001]","HB NWH MEDICARE","18450.35","","Case rate ($18,450.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,380.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,224.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $17,168.02. The transfer operating threshold is the transfer adjustment factor * $17,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,282.33. The transfer capital threshold is the transfer adjustment factor * $1,282.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18948.05","1038.65","18982.11","17","16444.68","19632.6317","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","41994.60","31495.95","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","16444.68","","Case rate ($16,780.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,380.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,224.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,497.96. The transfer operating threshold is the transfer adjustment factor * $17,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,282.33. The transfer capital threshold is the transfer adjustment factor * $1,282.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19971.59","19971.59","19971.59","1 through 10","16444.68","19632.6317","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","41994.60","31495.95","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16444.68","","Case rate ($16,780.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,237.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,380.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,224.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,497.96. The transfer operating threshold is the transfer adjustment factor * $17,237.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,282.33. The transfer capital threshold is the transfer adjustment factor * $1,282.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16956.08","16938.42","24140.52","1 through 10","16444.68","19632.6317","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","24307.85","18230.89","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7820.06","","Case rate ($7,820.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,033.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,175.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,539.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,222.46. The transfer operating threshold is the transfer adjustment factor * $8,033.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.60. The transfer capital threshold is the transfer adjustment factor * $597.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8671.68","8671.68","8671.68","1 through 10","7663.66","9265.19","other","Inpatient Replacement Plans DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","24307.85","18230.89","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6651.87","6651.87","6651.87","1 through 10","7663.66","9265.19","case rate",""
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","24307.85","18230.89","MEDICARE [2001]","HB NWH MEDICARE","7820.06","","Case rate ($7,820.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,033.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,175.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,539.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,222.46. The transfer operating threshold is the transfer adjustment factor * $8,033.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.60. The transfer capital threshold is the transfer adjustment factor * $597.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8796.86","6515.75","8812.68","14","7663.66","9265.19","other","Inpatient Replacement Plans DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","24307.85","18230.89","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7663.66","","Case rate ($7,820.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,033.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,175.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,539.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,222.46. The transfer operating threshold is the transfer adjustment factor * $8,033.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.60. The transfer capital threshold is the transfer adjustment factor * $597.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7862.50","7862.50","7862.50","1 through 10","7663.66","9265.19","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","24307.85","18230.89","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","7663.66","","Case rate ($7,820.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,033.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,175.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,539.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,222.46. The transfer operating threshold is the transfer adjustment factor * $8,033.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $597.60. The transfer capital threshold is the transfer adjustment factor * $597.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8963.94","8963.94","8963.94","1 through 10","7663.66","9265.19","other","Inpatient DRG"
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","214.00","160.50","AETNA [1001]","HB CH AETNA HMO / PPO","124.76","58.3","","117.94","117.94","117.94","1 through 10","25.02","203.3","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","95.12","44.45","","159.91","93.39","159.91","1 through 10","25.02","203.3","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","214.00","160.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.90","59.3","","365.67","121.89","365.67","1 through 10","26.33","167.88","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.88","78.45","","159.91","82.70","159.91","1 through 10","26.33","167.88","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","100.36","100.36","100.36","33","15.19","172.9","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","182.00","136.50","TRICARE [160005]","HB NWH TRICARE","172.90","95","","17.75","17.75","18.68","1 through 10","15.19","172.9","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","182.00","136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.93","59.3","","103.72","103.72","103.72","38","15.99","142.78","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.90","44.45","","136.08","80.64","136.08","1 through 10","15.99","142.78","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","136.08","80.64","136.08","42","15.99","142.78","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","140.00","105.00","AETNA [1001]","HB CH AETNA HMO / PPO","81.62","58.3","","77.11","77.11","77.11","18","11.81","133","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","140.00","105.00","TRICARE [160005]","HB NWH TRICARE","133.00","95","","13.79","13.79","13.79","1 through 10","11.81","133","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","140.00","105.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.02","59.3","","79.70","79.70","79.70","21","12.43","109.83","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.23","44.45","","104.56","104.56","104.56","1 through 10","12.43","109.83","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.83","78.45","","104.56","61.96","104.56","22","12.43","109.83","percent of total billed charges",""
"SEPTAL BUTTON NASAL 2 PART 152","SUP-ITM-10216619","CDM","L8699","HCPCS","0278","RC","","","","outpatient","","","891.42","668.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","528.61","59.3","","184.04","184.04","184.04","1 through 10","445.71","699.32","percent of total billed charges",""
"Septic Arthritis With McC","548","MS-DRG","","","","","","","","inpatient","","","61405.99","46054.49","MEDICARE [2001]","HB NWH MEDICARE","16729.19","","Case rate ($16,729.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,185.41, add-ons for qualifying new technology services are included. If operating cost exceeds $62,327.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,220.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $15,450.75. The transfer operating threshold is the transfer adjustment factor * $17,185.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,278.43. The transfer capital threshold is the transfer adjustment factor * $1,278.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19227.69","19227.69","19227.69","1 through 10","16394.61","19820.69","other","Inpatient Replacement Plans DRG"
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25873.13","","Standard inlier is a Case rate ($25,873.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,672.79) for the length of stay and the standard reimbursement.","43090.40","43087.70","71280.72","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27792.90","","Standard inlier is a Case rate ($27,792.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,945.09) for the length of stay and the standard reimbursement.","46279.73","20646.09","48483.52","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12583.0938","","Fee schedule rate ($66,165.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12583.0938","66165.30","66165.30","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13212.1841","","Fee schedule rate ($69,473.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13212.1841","69473.24","69473.24","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","72781.16","","Fee schedule rate ($72,781.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72781.16","72781.16","72781.16","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","MASSHEALTH [3001]","HB NWH MEDICAID","9871.18","","Case rate ($10,634.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,064.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22309.85","2158.05","22309.85","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","27639.38","","Fee schedule rate ($27,639.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","84648.19","84648.19","84648.19","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","58910.54","","Fee schedule rate ($58,910.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58910.54","58910.54","58910.54","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","9871.18","","Case rate ($10,634.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,064.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22309.86","22309.86","22309.86","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","50485.40","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9871.18","","Case rate ($10,634.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,064.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17087.88","17087.88","17087.88","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25873.13","","Standard inlier is a Case rate ($25,873.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,672.79) for the length of stay and the standard reimbursement.","24699.47","2858.02","25873.13","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27792.90","","Standard inlier is a Case rate ($27,792.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,945.09) for the length of stay and the standard reimbursement.","26529.58","3215.80","27792.90","20","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12583.0938","","Fee schedule rate ($30,972.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12583.0938","30972.12","30972.12","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13212.1841","","Fee schedule rate ($32,520.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13212.1841","31266.90","31266.90","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","MASSHEALTH [3001]","HB NWH MEDICAID","9871.18","","Case rate ($10,634.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,064.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10661.99","1471.44","10661.99","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","11810.62","","Fee schedule rate ($11,810.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11810.66","11810.66","11810.66","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13894.90","","Fee schedule rate ($13,894.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13490.08","13490.08","13490.08","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","14589.12","","Fee schedule rate ($14,589.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14589.12","14589.12","14589.12","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29615.57","","Fee schedule rate ($29,615.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29615.57","29615.57","29615.57","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","34449.18","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","9871.18","","Case rate ($10,634.64). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,064.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7637.53","1621.64","13327.49","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","17011.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13686.72","","Standard inlier is a Case rate ($13,686.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,690, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,942.88) for the length of stay and the standard reimbursement.","13686.72","13686.72","13686.72","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","17011.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14702.27","","Standard inlier is a Case rate ($14,702.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,690, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,086.93) for the length of stay and the standard reimbursement.","14033.98","14033.98","14702.27","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","17011.81","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","4604.88","","Case rate ($4,961.03). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,391.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $710.75 and the sum of the standard inlier and any outlier amount.","4973.79","4973.79","4973.79","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17601.77","","Standard inlier is a Case rate ($17,601.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,498.64) for the length of stay and the standard reimbursement.","16801.91","16801.91","17601.77","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18907.81","","Standard inlier is a Case rate ($18,907.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,683.88) for the length of stay and the standard reimbursement.","18907.81","14180.86","18907.81","12","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12583.0938","","Fee schedule rate ($18,082.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12583.0938","15370.16","18082.22","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13212.1841","","Fee schedule rate ($18,986.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13212.1841","18986.24","18986.24","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","MASSHEALTH [3001]","HB NWH MEDICAID","6160.78","","Case rate ($6,637.27). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,067.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6654.34","1136.80","6654.34","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","20176.04","","Fee schedule rate ($20,176.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20176.04","20176.04","20176.04","1 through 10","1468","109171.74","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","21839.56","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6160.78","","Case rate ($6,637.27). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,067.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7272.22","7272.22","7272.22","1 through 10","1468","109171.74","case rate",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","185178.64","138883.98","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","61679.82","","Case rate ($59,883.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $61,516.43, add-ons for qualifying new technology services are included. If operating cost exceeds $106,658.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,518.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $55,307.10. The transfer operating threshold is the transfer adjustment factor * $61,516.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,576.22. The transfer capital threshold is the transfer adjustment factor * $4,576.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","62308.93","62308.93","62308.93","1 through 10","58685.65","68875.8961","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","185178.64","138883.98","MEDICARE [2001]","HB NWH MEDICARE","59883.32","","Case rate ($59,883.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $61,516.43, add-ons for qualifying new technology services are included. If operating cost exceeds $106,658.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,518.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $55,307.10. The transfer operating threshold is the transfer adjustment factor * $61,516.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,576.22. The transfer capital threshold is the transfer adjustment factor * $4,576.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","66513.38","41496.26","88418.24","1 through 10","58685.65","68875.8961","other","Inpatient Replacement Plans DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","185178.64","138883.98","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","58685.65","","Case rate ($59,883.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $61,516.43, add-ons for qualifying new technology services are included. If operating cost exceeds $106,658.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,518.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $55,307.10. The transfer operating threshold is the transfer adjustment factor * $61,516.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,576.22. The transfer capital threshold is the transfer adjustment factor * $4,576.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","66288.15","66288.15","66288.15","1 through 10","58685.65","68875.8961","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","185178.64","138883.98","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","58685.65","","Case rate ($59,883.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $61,516.43, add-ons for qualifying new technology services are included. If operating cost exceeds $106,658.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $7,518.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $55,307.10. The transfer operating threshold is the transfer adjustment factor * $61,516.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,576.22. The transfer capital threshold is the transfer adjustment factor * $4,576.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","59314.68","59314.68","59314.68","1 through 10","58685.65","68875.8961","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Age >17 With McC","871","TRIS-DRG","","","","","","","","inpatient","","","170345.26","","TRICARE [160005]","HB NWH TRICARE","13994.49","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($19,621.10). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,265.46, and the first day is paid a rate of $8,530.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,265.46, and the first day is paid a rate of $8,530.91. The transfer payment is capped at $17,692.60. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $63,442.54 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.59999990463257). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $17,692.60. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,265.46, and the first day is paid a rate of $8,530.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,265.46, and the first day is paid a rate of $8,530.91. The transfer payment is capped at $17,692.60. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $63,442.54 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.59999990463257). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","21137.97","21137.97","21137.97","1 through 10","13994.49","13994.49","other","Inpatient DRGs"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Age >17 Without McC","872","TRIS-DRG","","","","","","","","inpatient","","","19557.77","","TRICARE [160005]","HB NWH TRICARE","6364.21","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($8,923.00). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,186.79, and the first day is paid a rate of $6,373.57. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,186.79, and the first day is paid a rate of $6,373.57. The transfer payment is capped at $8,045.99. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $52,744.44 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.79999995231628). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,248.82), capped at $8,045.99. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,186.79, and the first day is paid a rate of $6,373.57. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,186.79, and the first day is paid a rate of $6,373.57. The transfer payment is capped at $8,045.99. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $52,744.44 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.79999995231628). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","9379.73","9379.73","9379.73","1 through 10","6364.21","6364.21","other","Inpatient DRGs"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","17334.56","","Case rate ($16,829.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,543.57. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17566.35","17561.03","17602.43","13","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","18504.64","","Case rate ($18,504.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,218.54. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16920.09","16919.85","18460.12","14","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6392.51","6392.51","22309.86","1 through 10","16493.08","19939.76","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","FALLON HEALTH [1008]","HB NWH MEDICARE","18504.64","","Case rate ($18,504.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,218.54. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25911.90","25911.90","25911.90","1 through 10","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","MEDICARE [2001]","HB NWH MEDICARE","18504.64","","Case rate ($18,504.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,218.54. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18726.61","11485.04","18760.28","366","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","MOLINA [1014]","HB NWH MEDICARE","18504.64","","Case rate ($18,504.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,218.54. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27617.04","27617.04","27617.04","1 through 10","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","16493.08","","Case rate ($16,829.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,543.57. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16729.86","10246.02","16767.86","45","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","16493.08","","Case rate ($16,829.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,543.57. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18799.72","837.67","25675.72","1 through 10","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","42868.31","32151.23","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","16493.08","","Case rate ($16,829.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,288.65, add-ons for qualifying new technology services are included. If operating cost exceeds $62,430.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,543.57. The transfer operating threshold is the transfer adjustment factor * $17,288.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.11. The transfer capital threshold is the transfer adjustment factor * $1,286.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16729.79","13652.45","16778.19","31","16493.08","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","9131.76","","Case rate ($8,865.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,107.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,249.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,188.28. The transfer operating threshold is the transfer adjustment factor * $9,107.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.51. The transfer capital threshold is the transfer adjustment factor * $677.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9261.97","9261.97","9261.97","1 through 10","8688.47","10504.17","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9748.16","","Case rate ($9,748.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,107.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,249.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,070.65. The transfer operating threshold is the transfer adjustment factor * $9,107.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.51. The transfer capital threshold is the transfer adjustment factor * $677.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8967.52","8967.52","8967.52","1 through 10","8688.47","10504.17","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","1663.59","1663.59","1663.59","1 through 10","8688.47","10504.17","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","MEDICARE [2001]","HB NWH MEDICARE","9748.16","","Case rate ($9,748.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,107.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,249.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,070.65. The transfer operating threshold is the transfer adjustment factor * $9,107.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.51. The transfer capital threshold is the transfer adjustment factor * $677.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9840.04","8433.90","9857.73","67","8688.47","10504.17","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","8688.47","","Case rate ($8,865.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,107.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,249.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,188.28. The transfer operating threshold is the transfer adjustment factor * $9,107.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.51. The transfer capital threshold is the transfer adjustment factor * $677.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8813.64","8796.84","8820.81","1 through 10","8688.47","10504.17","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","24098.82","18074.11","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8688.47","","Case rate ($8,865.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $9,107.58, add-ons for qualifying new technology services are included. If operating cost exceeds $54,249.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,619.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,188.28. The transfer operating threshold is the transfer adjustment factor * $9,107.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $677.51. The transfer capital threshold is the transfer adjustment factor * $677.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11197.81","8806.64","14713.18","1 through 10","8688.47","10504.17","other","Inpatient DRG"
"Serotonin","PX-30000670","CDM","84260","CPT","0301","RC","","","","outpatient","","","259.00","194.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","153.59","59.3","","147.67","147.67","147.67","1 through 10","31.95","203.19","percent of total billed charges",""
"Serotonin","PX-30000670","CDM","84260","CPT","0301","RC","","","","outpatient","","","259.00","194.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","203.19","78.45","","193.74","193.74","193.74","1 through 10","31.95","203.19","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","AETNA [1001]","HB CH AETNA HMO / PPO","2070.82","58.3","","464.71","67.87","1012.10","221","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2070.82","58.3","","293.04","293.04","293.04","11","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1882.56","53","","983.89","983.89","983.89","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2060.16","58","","677.18","677.18","677.18","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2220.00","62.5","","46.58","46.58","46.58","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2592.96","73","","747.15","747.15","747.15","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1578.86","44.45","","1141.67","481.21","1141.67","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1578.86","44.45","","76.54","76.54","76.54","1 through 10","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3552.00","2664.00","WELLPOINT [1015]","HB CH WELLPOINT","2767.36","77.91","","273.64","94.28","1367.51","138","1578.86","2767.36","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3552.00","2664.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2106.34","59.3","","720.78","230.14","2010.94","427","1776","2786.54","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3552.00","2664.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2106.34","59.3","","344.45","344.45","344.45","1 through 10","1776","2786.54","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3552.00","2664.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2786.54","78.45","","1120.13","1120.13","1120.13","1 through 10","1776","2786.54","percent of total billed charges",""
"SERRATO LARGE DIAMETER SCREW TRAY","SUP-ITM-10256972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3552.00","2664.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2786.54","78.45","","456.17","105.33","1284.66","242","1776","2786.54","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","13.33","131.1","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","77.45","77.45","157.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","61.05","61.05","61.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","13.33","131.1","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","77.45","77.45","157.05","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","61.05","61.05","61.05","1 through 10","11.72","108.26","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","464.71","67.87","1012.10","221","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","293.04","293.04","293.04","11","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","983.89","983.89","983.89","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","677.18","677.18","677.18","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","46.58","46.58","46.58","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","747.15","747.15","747.15","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","1141.67","481.21","1141.67","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","76.54","76.54","76.54","1 through 10","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","273.64","94.28","1367.51","138","60.01","105.18","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","720.78","230.14","2010.94","427","67.5","105.91","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","344.45","344.45","344.45","1 through 10","67.5","105.91","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1120.13","1120.13","1120.13","1 through 10","67.5","105.91","percent of total billed charges",""
"SET BLOCKER XIA TITANIUM 4.5MM SCREW","SUP-ITM-10021353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","456.17","105.33","1284.66","242","67.5","105.91","percent of total billed charges",""
"SET CATHETER 30FR 10MM 15CM DILATATION BALLOON URETERAL PTFE BALLOON INFLATOR CS/1EA","SUP-ITM-10046601","CDM","C1726","HCPCS","0272","RC","","","","both","","","714.00","535.50","WELLPOINT [1015]","HB CH WELLPOINT","556.28","77.91","","582.67","582.67","582.67","1 through 10","317.37","556.28","percent of total billed charges",""
"SET CATHETER 30FR 10MM 15CM DILATATION BALLOON URETERAL PTFE BALLOON INFLATOR CS/1EA","SUP-ITM-10046601","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","714.00","535.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","560.13","78.45","","394.74","331.66","1115.07","1 through 10","357","560.13","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","AETNA [1001]","HB CH AETNA HMO / PPO","3031.60","58.3","","1530.90","1160.93","1884.08","89","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2756.00","53","","5253.92","5253.92","5253.92","1 through 10","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3016.00","58","","12181.47","12181.47","12181.47","1 through 10","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3250.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2311.40","44.45","","1910.74","891.94","1910.74","1 through 10","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","WELLPOINT [1015]","HB CH WELLPOINT","4051.32","77.91","","1829.79","1561.50","2617.12","88","2311.4","4051.32","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3083.60","59.3","","1359.46","1201.30","1689.00","61","2600","4079.4","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3083.60","59.3","","1718.92","1718.92","1718.92","1 through 10","2600","4079.4","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4079.40","78.45","","1910.74","1019.06","2344.84","74","2600","4079.4","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","both","","","585.00","438.75","AETNA [1001]","HB CH AETNA HMO / PPO","341.06","58.3","","34.87","34.02","34.87","1 through 10","260.03","455.77","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","both","","","585.00","438.75","WELLPOINT [1015]","HB CH WELLPOINT","455.77","77.91","","81.73","36.01","81.73","1 through 10","260.03","455.77","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","35.15","35.15","162.55","1 through 10","292.5","458.93","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","767.10","575.32","WELLPOINT [1015]","HB CH WELLPOINT","597.65","77.91","","582.67","582.67","582.67","1 through 10","340.98","597.65","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","767.10","575.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","601.79","78.45","","394.74","331.66","1115.07","1 through 10","383.55","601.79","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","451.50","338.62","AETNA [1001]","HB CH AETNA HMO / PPO","263.22","58.3","","52.78","35.48","309.60","1 through 10","200.69","351.76","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","451.50","338.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","239.30","53","","173.31","173.31","173.31","1 through 10","200.69","351.76","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","451.50","338.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","282.19","62.5","","26.48","26.48","26.48","1 through 10","200.69","351.76","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","451.50","338.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.69","44.45","","127.34","127.34","127.34","1 through 10","200.69","351.76","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","451.50","338.62","WELLPOINT [1015]","HB CH WELLPOINT","351.76","77.91","","99.24","60.15","134.68","19","200.69","351.76","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","267.74","59.3","","59.44","59.44","59.44","1 through 10","225.75","354.2","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","354.20","78.45","","239.87","239.87","239.87","1 through 10","225.75","354.2","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.20","78.45","","77.27","46.21","95.91","26","225.75","354.2","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","464.71","67.87","1012.10","221","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","293.04","293.04","293.04","11","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","983.89","983.89","983.89","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","677.18","677.18","677.18","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","46.58","46.58","46.58","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","747.15","747.15","747.15","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1141.67","481.21","1141.67","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","76.54","76.54","76.54","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","273.64","94.28","1367.51","138","1666.88","2921.63","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","720.78","230.14","2010.94","427","1875","2941.88","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","344.45","344.45","344.45","1 through 10","1875","2941.88","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1120.13","1120.13","1120.13","1 through 10","1875","2941.88","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","456.17","105.33","1284.66","242","1875","2941.88","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","AETNA [1001]","HB CH AETNA HMO / PPO","1054.17","58.3","","464.71","67.87","1012.10","221","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1054.17","58.3","","293.04","293.04","293.04","11","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.34","53","","983.89","983.89","983.89","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1048.75","58","","677.18","677.18","677.18","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1130.12","62.5","","46.58","46.58","46.58","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1319.98","73","","747.15","747.15","747.15","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.74","44.45","","1141.67","481.21","1141.67","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.74","44.45","","76.54","76.54","76.54","1 through 10","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","WELLPOINT [1015]","HB CH WELLPOINT","1408.76","77.91","","273.64","94.28","1367.51","138","803.74","1408.76","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","1072.26","59.3","","720.78","230.14","2010.94","427","904.1","1418.53","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1072.26","59.3","","344.45","344.45","344.45","1 through 10","904.1","1418.53","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1418.53","78.45","","1120.13","1120.13","1120.13","1 through 10","904.1","1418.53","percent of total billed charges",""
"SET GRAFT 3.0ML BONE NORIAN FIBER CALCIUM PHOSPHATE BIOCOMPATIBLE VOID FILLER FAST DRILLABLE PUTTY","SUP-ITM-10118184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.53","78.45","","456.17","105.33","1284.66","242","904.1","1418.53","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","both","","","390.00","292.50","AETNA [1001]","HB CH AETNA HMO / PPO","227.37","58.3","","188.13","151.57","188.13","1 through 10","173.36","303.85","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.70","53","","175.85","175.85","175.85","1 through 10","173.36","303.85","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","both","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.36","44.45","","255.09","255.09","255.09","1 through 10","173.36","303.85","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","both","","","390.00","292.50","WELLPOINT [1015]","HB CH WELLPOINT","303.85","77.91","","261.33","130.66","261.33","1 through 10","173.36","303.85","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.27","59.3","","194.43","189.79","327.42","11","195","305.96","percent of total billed charges",""
"SET KIT 3.7FRX8 TO 20CM STENT UROLGCL PIGTL FLEX TIP TETHER GUIDWR COTD POLYURET POSTNR RADIOPQ CATH Y C","SUP-ITM-10078526","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","255.09","151.17","255.09","1 through 10","195","305.96","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","464.71","67.87","1012.10","221","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.88","58.3","","293.04","293.04","293.04","11","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","983.89","983.89","983.89","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.50","58","","677.18","677.18","677.18","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.13","62.5","","46.58","46.58","46.58","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","747.15","747.15","747.15","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","1141.67","481.21","1141.67","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","76.54","76.54","76.54","1 through 10","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","273.64","94.28","1367.51","138","500.06","876.49","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","720.78","230.14","2010.94","427","562.5","882.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.13","59.3","","344.45","344.45","344.45","1 through 10","562.5","882.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","1120.13","1120.13","1120.13","1 through 10","562.5","882.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","456.17","105.33","1284.66","242","562.5","882.56","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","AETNA [1001]","HB CH AETNA HMO / PPO","473.54","58.3","","464.71","67.87","1012.10","221","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","473.54","58.3","","293.04","293.04","293.04","11","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","430.49","53","","983.89","983.89","983.89","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","471.11","58","","677.18","677.18","677.18","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","507.66","62.5","","46.58","46.58","46.58","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","592.94","73","","747.15","747.15","747.15","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.05","44.45","","1141.67","481.21","1141.67","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.05","44.45","","76.54","76.54","76.54","1 through 10","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","both","","","812.25","609.19","WELLPOINT [1015]","HB CH WELLPOINT","632.82","77.91","","273.64","94.28","1367.51","138","361.05","632.82","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","812.25","609.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","481.66","59.3","","720.78","230.14","2010.94","427","406.13","637.21","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","812.25","609.19","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","481.66","59.3","","344.45","344.45","344.45","1 through 10","406.13","637.21","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","812.25","609.19","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","637.21","78.45","","1120.13","1120.13","1120.13","1 through 10","406.13","637.21","percent of total billed charges",""
"SET NEEDLE DELIVERY ULTRA FAST FIX AB MENISCAL REPAIR CURVED SPLIT CANNULA","SUP-ITM-10036452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","812.25","609.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","637.21","78.45","","456.17","105.33","1284.66","242","406.13","637.21","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","822.00","616.50","AETNA [1001]","HB CH AETNA HMO / PPO","479.23","58.3","","130.62","100.02","466.07","54","365.38","640.42","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","822.00","616.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.38","44.45","","135.62","135.62","135.62","1 through 10","365.38","640.42","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","822.00","616.50","WELLPOINT [1015]","HB CH WELLPOINT","640.42","77.91","","647.41","134.45","647.41","16","365.38","640.42","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","822.00","616.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","487.45","59.3","","135.00","103.37","481.69","69","411","644.86","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","822.00","616.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","644.86","78.45","","177.11","126.85","631.95","31","411","644.86","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","AETNA [1001]","HB CH AETNA HMO / PPO","513.17","58.3","","464.71","67.87","1012.10","221","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.17","58.3","","293.04","293.04","293.04","11","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.52","53","","983.89","983.89","983.89","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","510.53","58","","677.18","677.18","677.18","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","550.14","62.5","","46.58","46.58","46.58","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.57","73","","747.15","747.15","747.15","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.26","44.45","","1141.67","481.21","1141.67","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.26","44.45","","76.54","76.54","76.54","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","WELLPOINT [1015]","HB CH WELLPOINT","685.79","77.91","","273.64","94.28","1367.51","138","391.26","685.79","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.98","59.3","","720.78","230.14","2010.94","427","440.12","690.54","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","521.98","59.3","","344.45","344.45","344.45","1 through 10","440.12","690.54","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","690.54","78.45","","1120.13","1120.13","1120.13","1 through 10","440.12","690.54","percent of total billed charges",""
"SET SCREW 100MM 12.7 BONE LAG DHS/DCS ONE STEP SS 22 THREAD","SUP-ITM-10038165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.54","78.45","","456.17","105.33","1284.66","242","440.12","690.54","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","AETNA [1001]","HB CH AETNA HMO / PPO","513.17","58.3","","464.71","67.87","1012.10","221","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.17","58.3","","293.04","293.04","293.04","11","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.52","53","","983.89","983.89","983.89","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","510.53","58","","677.18","677.18","677.18","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","550.14","62.5","","46.58","46.58","46.58","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.57","73","","747.15","747.15","747.15","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.26","44.45","","1141.67","481.21","1141.67","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.26","44.45","","76.54","76.54","76.54","1 through 10","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.23","660.17","WELLPOINT [1015]","HB CH WELLPOINT","685.79","77.91","","273.64","94.28","1367.51","138","391.26","685.79","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.98","59.3","","720.78","230.14","2010.94","427","440.12","690.54","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","521.98","59.3","","344.45","344.45","344.45","1 through 10","440.12","690.54","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","690.54","78.45","","1120.13","1120.13","1120.13","1 through 10","440.12","690.54","percent of total billed charges",""
"SET SCREW 12.7X95MM BONE LAG CONDYLAR S/S CANC CANN SELF TAP NON LOCK","SUP-ITM-10004521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.23","660.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.54","78.45","","456.17","105.33","1284.66","242","440.12","690.54","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","2190.90","412.50","9264.59","16","60.01","105.18","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","1903.20","1903.20","3826.66","1 through 10","60.01","105.18","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","2186.25","2186.25","2186.25","32","60.01","105.18","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","5556.60","5556.60","5556.60","1 through 10","60.01","105.18","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","1955.15","885.83","3150.40","26","60.01","105.18","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","831.03","253.22","2394.88","18","67.5","105.91","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","2481.69","1563.74","8149.28","1 through 10","67.5","105.91","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","2190.90","412.50","9264.59","16","66.68","116.87","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","1903.20","1903.20","3826.66","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","2186.25","2186.25","2186.25","32","66.68","116.87","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","5556.60","5556.60","5556.60","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","1955.15","885.83","3150.40","26","66.68","116.87","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","831.03","253.22","2394.88","18","75","117.68","percent of total billed charges",""
"SET SCREW BONE VIRAGE TOP CLOSURE STANDARD","SUP-ITM-10185142","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","2481.69","1563.74","8149.28","1 through 10","75","117.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","464.71","67.87","1012.10","221","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","293.04","293.04","293.04","11","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","983.89","983.89","983.89","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","677.18","677.18","677.18","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","46.58","46.58","46.58","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","747.15","747.15","747.15","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1141.67","481.21","1141.67","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","76.54","76.54","76.54","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","273.64","94.28","1367.51","138","66.68","116.87","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","720.78","230.14","2010.94","427","75","117.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","344.45","344.45","344.45","1 through 10","75","117.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1120.13","1120.13","1120.13","1 through 10","75","117.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","456.17","105.33","1284.66","242","75","117.68","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","464.71","67.87","1012.10","221","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","293.04","293.04","293.04","11","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","983.89","983.89","983.89","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","87.00","58","","677.18","677.18","677.18","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","93.75","62.5","","46.58","46.58","46.58","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","747.15","747.15","747.15","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","1141.67","481.21","1141.67","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","76.54","76.54","76.54","1 through 10","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","273.64","94.28","1367.51","138","66.68","116.87","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","720.78","230.14","2010.94","427","75","117.68","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","88.95","59.3","","344.45","344.45","344.45","1 through 10","75","117.68","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1120.13","1120.13","1120.13","1 through 10","75","117.68","percent of total billed charges",""
"SET SCREW SPINE INFINITY STANDARD SNA","SUP-ITM-10260218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","456.17","105.33","1284.66","242","75","117.68","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","2190.90","412.50","9264.59","16","60.01","105.18","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","78.30","58","","1903.20","1903.20","3826.66","1 through 10","60.01","105.18","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","84.38","62.5","","2186.25","2186.25","2186.25","32","60.01","105.18","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","5556.60","5556.60","5556.60","1 through 10","60.01","105.18","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","1955.15","885.83","3150.40","26","60.01","105.18","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","831.03","253.22","2394.88","18","67.5","105.91","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","2481.69","1563.74","8149.28","1 through 10","67.5","105.91","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","973.11","729.83","WELLPOINT [1015]","HB CH WELLPOINT","758.15","77.91","","582.67","582.67","582.67","1 through 10","432.55","758.15","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","973.11","729.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","763.40","78.45","","394.74","331.66","1115.07","1 through 10","486.56","763.4","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","464.71","67.87","1012.10","221","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","293.04","293.04","293.04","11","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","983.89","983.89","983.89","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","526.35","58","","677.18","677.18","677.18","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","567.19","62.5","","46.58","46.58","46.58","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","747.15","747.15","747.15","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","1141.67","481.21","1141.67","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","76.54","76.54","76.54","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","273.64","94.28","1367.51","138","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","720.78","230.14","2010.94","427","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","538.15","59.3","","344.45","344.45","344.45","1 through 10","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","1120.13","1120.13","1120.13","1 through 10","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","456.17","105.33","1284.66","242","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","464.71","67.87","1012.10","221","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","293.04","293.04","293.04","11","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","983.89","983.89","983.89","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","526.35","58","","677.18","677.18","677.18","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","567.19","62.5","","46.58","46.58","46.58","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","747.15","747.15","747.15","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","1141.67","481.21","1141.67","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","76.54","76.54","76.54","1 through 10","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","273.64","94.28","1367.51","138","403.38","707.03","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","720.78","230.14","2010.94","427","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","538.15","59.3","","344.45","344.45","344.45","1 through 10","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","1120.13","1120.13","1120.13","1 through 10","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","456.17","105.33","1284.66","242","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","AETNA [1001]","HB CH AETNA HMO / PPO","494.09","58.3","","464.71","67.87","1012.10","221","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","494.09","58.3","","293.04","293.04","293.04","11","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","449.18","53","","983.89","983.89","983.89","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","491.55","58","","677.18","677.18","677.18","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","529.69","62.5","","46.58","46.58","46.58","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","618.68","73","","747.15","747.15","747.15","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.71","44.45","","1141.67","481.21","1141.67","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.71","44.45","","76.54","76.54","76.54","1 through 10","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","WELLPOINT [1015]","HB CH WELLPOINT","660.29","77.91","","273.64","94.28","1367.51","138","376.71","660.29","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","502.57","59.3","","720.78","230.14","2010.94","427","423.75","664.86","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","502.57","59.3","","344.45","344.45","344.45","1 through 10","423.75","664.86","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","664.86","78.45","","1120.13","1120.13","1120.13","1 through 10","423.75","664.86","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","664.86","78.45","","456.17","105.33","1284.66","242","423.75","664.86","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","AETNA [1001]","HB CH AETNA HMO / PPO","451.05","58.3","","188.13","151.57","188.13","1 through 10","343.9","602.77","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","410.05","53","","175.85","175.85","175.85","1 through 10","343.9","602.77","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","343.90","44.45","","255.09","255.09","255.09","1 through 10","343.9","602.77","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","WELLPOINT [1015]","HB CH WELLPOINT","602.77","77.91","","261.33","130.66","261.33","1 through 10","343.9","602.77","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","773.67","580.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","458.79","59.3","","194.43","189.79","327.42","11","386.84","606.94","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","773.67","580.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","606.94","78.45","","255.09","151.17","255.09","1 through 10","386.84","606.94","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","AETNA [1001]","HB CH AETNA HMO / PPO","48.82","58.3","","48.90","46.54","48.90","1 through 10","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.38","53","","91.65","91.65","91.65","1 through 10","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","48.57","58","","51.23","51.23","51.23","1 through 10","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","52.34","62.5","","65.12","36.89","65.12","1 through 10","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","61.13","73","","46.29","46.29","46.29","1 through 10","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","both","","","83.74","62.80","WELLPOINT [1015]","HB CH WELLPOINT","65.24","77.91","","64.65","45.40","120.92","18","37.22","65.24","percent of total billed charges",""
"SET TIP 4FR XCM ACCESS ADULT .018IN INTRODUCER VASCULAR TRANSITIONLESS DESIGN GUIDEWIRE MICROPUNCTURE SS DI","SUP-ITM-10008207","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","83.74","62.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.69","78.45","","276.77","63.10","312.43","11","41.87","65.69","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","196.18","18","21.3","169.1","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","304.14","12","22.41","139.64","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.12","44.45","","133.00","78.82","133.00","1 through 10","22.41","139.64","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","78.82","133.00","16","22.41","139.64","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.12","44.45","","133.00","133.00","133.00","1 through 10","22.41","139.64","percent of total billed charges",""
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","outpatient","","","3540.00","2655.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","1 through 10","979.79","2777.13","other","ASC "
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","AETNA [1001]","HB CH AETNA HMO / PPO","609.23","58.3","","464.71","67.87","1012.10","221","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","609.23","58.3","","293.04","293.04","293.04","11","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","553.84","53","","983.89","983.89","983.89","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","606.09","58","","677.18","677.18","677.18","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","653.12","62.5","","46.58","46.58","46.58","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","762.84","73","","747.15","747.15","747.15","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.50","44.45","","1141.67","481.21","1141.67","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.50","44.45","","76.54","76.54","76.54","1 through 10","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1044.99","783.74","WELLPOINT [1015]","HB CH WELLPOINT","814.15","77.91","","273.64","94.28","1367.51","138","464.5","814.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1044.99","783.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","619.68","59.3","","720.78","230.14","2010.94","427","522.5","819.79","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1044.99","783.74","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","619.68","59.3","","344.45","344.45","344.45","1 through 10","522.5","819.79","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1044.99","783.74","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","819.79","78.45","","1120.13","1120.13","1120.13","1 through 10","522.5","819.79","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1044.99","783.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","819.79","78.45","","456.17","105.33","1284.66","242","522.5","819.79","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","AETNA [1001]","HB CH AETNA HMO / PPO","616.71","58.3","","464.71","67.87","1012.10","221","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","616.71","58.3","","293.04","293.04","293.04","11","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","560.65","53","","983.89","983.89","983.89","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","613.54","58","","677.18","677.18","677.18","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","661.14","62.5","","46.58","46.58","46.58","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","772.22","73","","747.15","747.15","747.15","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.21","44.45","","1141.67","481.21","1141.67","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.21","44.45","","76.54","76.54","76.54","1 through 10","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","WELLPOINT [1015]","HB CH WELLPOINT","824.16","77.91","","273.64","94.28","1367.51","138","470.21","824.16","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","627.29","59.3","","720.78","230.14","2010.94","427","528.92","829.87","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","627.29","59.3","","344.45","344.45","344.45","1 through 10","528.92","829.87","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","829.87","78.45","","1120.13","1120.13","1120.13","1 through 10","528.92","829.87","percent of total billed charges",""
"SHAFT BASE 1.3MM 2 HOLE HEAD 5 LOCKING PHALANGEAL PL","SUP-ITM-10164650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","829.87","78.45","","456.17","105.33","1284.66","242","528.92","829.87","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1510.05","1132.54","AETNA [1001]","HB CH AETNA HMO / PPO","880.36","58.3","","2190.90","412.50","9264.59","16","671.22","1176.48","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1510.05","1132.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","875.83","58","","1903.20","1903.20","3826.66","1 through 10","671.22","1176.48","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1510.05","1132.54","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","943.78","62.5","","2186.25","2186.25","2186.25","32","671.22","1176.48","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1510.05","1132.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1102.34","73","","5556.60","5556.60","5556.60","1 through 10","671.22","1176.48","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1510.05","1132.54","WELLPOINT [1015]","HB CH WELLPOINT","1176.48","77.91","","1955.15","885.83","3150.40","26","671.22","1176.48","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1510.05","1132.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","895.46","59.3","","831.03","253.22","2394.88","18","755.03","1184.63","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1510.05","1132.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1184.63","78.45","","2481.69","1563.74","8149.28","1 through 10","755.03","1184.63","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","both","","","1617.21","1212.91","AETNA [1001]","HB CH AETNA HMO / PPO","942.83","58.3","","2190.90","412.50","9264.59","16","718.85","1259.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","both","","","1617.21","1212.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","937.98","58","","1903.20","1903.20","3826.66","1 through 10","718.85","1259.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","both","","","1617.21","1212.91","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1010.76","62.5","","2186.25","2186.25","2186.25","32","718.85","1259.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","both","","","1617.21","1212.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1180.56","73","","5556.60","5556.60","5556.60","1 through 10","718.85","1259.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","both","","","1617.21","1212.91","WELLPOINT [1015]","HB CH WELLPOINT","1259.97","77.91","","1955.15","885.83","3150.40","26","718.85","1259.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1617.21","1212.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","959.01","59.3","","831.03","253.22","2394.88","18","808.61","1268.7","percent of total billed charges",""
"SHAFT FIBULA 8 15X60MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010286","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1617.21","1212.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1268.70","78.45","","2481.69","1563.74","8149.28","1 through 10","808.61","1268.7","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","AETNA [1001]","HB CH AETNA HMO / PPO","2181.63","58.3","","464.71","67.87","1012.10","221","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2181.63","58.3","","293.04","293.04","293.04","11","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1983.30","53","","983.89","983.89","983.89","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2170.41","58","","677.18","677.18","677.18","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2338.80","62.5","","46.58","46.58","46.58","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2731.72","73","","747.15","747.15","747.15","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.35","44.45","","1141.67","481.21","1141.67","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.35","44.45","","76.54","76.54","76.54","1 through 10","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","WELLPOINT [1015]","HB CH WELLPOINT","2915.45","77.91","","273.64","94.28","1367.51","138","1663.35","2915.45","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2219.05","59.3","","720.78","230.14","2010.94","427","1871.04","2935.66","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2219.05","59.3","","344.45","344.45","344.45","1 through 10","1871.04","2935.66","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2935.66","78.45","","1120.13","1120.13","1120.13","1 through 10","1871.04","2935.66","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2935.66","78.45","","456.17","105.33","1284.66","242","1871.04","2935.66","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","464.71","67.87","1012.10","221","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","682.11","58.3","","293.04","293.04","293.04","11","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","620.10","53","","983.89","983.89","983.89","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","678.60","58","","677.18","677.18","677.18","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","731.25","62.5","","46.58","46.58","46.58","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","747.15","747.15","747.15","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","1141.67","481.21","1141.67","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","76.54","76.54","76.54","1 through 10","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","273.64","94.28","1367.51","138","520.07","911.55","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","720.78","230.14","2010.94","427","585","917.87","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","693.81","59.3","","344.45","344.45","344.45","1 through 10","585","917.87","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","1120.13","1120.13","1120.13","1 through 10","585","917.87","percent of total billed charges",""
"SHANK SPINE 6.5X45MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10151450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","456.17","105.33","1284.66","242","585","917.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","AETNA [1001]","HB CH AETNA HMO / PPO","270.73","58.3","","48.90","46.54","48.90","1 through 10","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.12","53","","91.65","91.65","91.65","1 through 10","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","269.33","58","","51.23","51.23","51.23","1 through 10","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","290.23","62.5","","65.12","36.89","65.12","1 through 10","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.99","73","","46.29","46.29","46.29","1 through 10","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","WELLPOINT [1015]","HB CH WELLPOINT","361.79","77.91","","64.65","45.40","120.92","18","206.41","361.79","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","464.37","348.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.30","78.45","","276.77","63.10","312.43","11","232.19","364.3","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","48.90","46.54","48.90","1 through 10","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1230.66","53","","91.65","91.65","91.65","1 through 10","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1346.76","58","","51.23","51.23","51.23","1 through 10","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1451.25","62.5","","65.12","36.89","65.12","1 through 10","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1695.06","73","","46.29","46.29","46.29","1 through 10","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","64.65","45.40","120.92","18","1032.13","1809.07","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","276.77","63.10","312.43","11","1161","1821.61","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","AETNA [1001]","HB CH AETNA HMO / PPO","804.54","58.3","","48.90","46.54","48.90","1 through 10","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","731.40","53","","91.65","91.65","91.65","1 through 10","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","800.40","58","","51.23","51.23","51.23","1 through 10","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","862.50","62.5","","65.12","36.89","65.12","1 through 10","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1007.40","73","","46.29","46.29","46.29","1 through 10","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1380.00","1035.00","WELLPOINT [1015]","HB CH WELLPOINT","1075.16","77.91","","64.65","45.40","120.92","18","613.41","1075.16","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1082.61","78.45","","276.77","63.10","312.43","11","690","1082.61","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","both","","","109.80","82.35","AETNA [1001]","HB CH AETNA HMO / PPO","64.01","58.3","","28.02","15.31","28.02","1 through 10","48.81","85.55","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","both","","","109.80","82.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","58.19","53","","79.50","79.50","79.50","1 through 10","48.81","85.55","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","both","","","109.80","82.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.81","44.45","","25.51","25.51","25.51","1 through 10","48.81","85.55","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","both","","","109.80","82.35","WELLPOINT [1015]","HB CH WELLPOINT","85.55","77.91","","135.65","59.07","274.09","13","48.81","85.55","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","109.80","82.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.11","59.3","","43.95","43.95","43.95","1 through 10","54.9","86.14","percent of total billed charges",""
"SHEATH GUIDING 10MMX22CM RENAL X-FORCE PTFE BEVELED TIP RADIOPAQUE BX/5EA","SUP-ITM-10277675","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","109.80","82.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.14","78.45","","57.66","15.03","149.03","11","54.9","86.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","AETNA [1001]","HB CH AETNA HMO / PPO","15.74","58.3","","48.90","46.54","48.90","1 through 10","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","14.31","53","","91.65","91.65","91.65","1 through 10","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","15.66","58","","51.23","51.23","51.23","1 through 10","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","16.88","62.5","","65.12","36.89","65.12","1 through 10","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","19.71","73","","46.29","46.29","46.29","1 through 10","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","27.00","20.25","WELLPOINT [1015]","HB CH WELLPOINT","21.04","77.91","","64.65","45.40","120.92","18","12","21.04","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","27.00","20.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","21.18","78.45","","276.77","63.10","312.43","11","13.5","21.18","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","AETNA [1001]","HB CH AETNA HMO / PPO","40.23","58.3","","48.90","46.54","48.90","1 through 10","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","36.57","53","","91.65","91.65","91.65","1 through 10","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","40.02","58","","51.23","51.23","51.23","1 through 10","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","43.13","62.5","","65.12","36.89","65.12","1 through 10","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","50.37","73","","46.29","46.29","46.29","1 through 10","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","69.00","51.75","WELLPOINT [1015]","HB CH WELLPOINT","53.76","77.91","","64.65","45.40","120.92","18","30.67","53.76","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","69.00","51.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","54.13","78.45","","276.77","63.10","312.43","11","34.5","54.13","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","48.90","46.54","48.90","1 through 10","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","91.65","91.65","91.65","1 through 10","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","51.23","51.23","51.23","1 through 10","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","65.12","36.89","65.12","1 through 10","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","46.29","46.29","46.29","1 through 10","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","64.65","45.40","120.92","18","340.04","596.01","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","276.77","63.10","312.43","11","382.5","600.14","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","AETNA [1001]","HB CH AETNA HMO / PPO","379.53","58.3","","464.71","67.87","1012.10","221","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.53","58.3","","293.04","293.04","293.04","11","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.03","53","","983.89","983.89","983.89","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","377.58","58","","677.18","677.18","677.18","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","406.88","62.5","","46.58","46.58","46.58","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.23","73","","747.15","747.15","747.15","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.37","44.45","","1141.67","481.21","1141.67","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.37","44.45","","76.54","76.54","76.54","1 through 10","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","WELLPOINT [1015]","HB CH WELLPOINT","507.19","77.91","","273.64","94.28","1367.51","138","289.37","507.19","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.04","59.3","","720.78","230.14","2010.94","427","325.5","510.71","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","386.04","59.3","","344.45","344.45","344.45","1 through 10","325.5","510.71","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","510.71","78.45","","1120.13","1120.13","1120.13","1 through 10","325.5","510.71","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.71","78.45","","456.17","105.33","1284.66","242","325.5","510.71","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","AETNA [1001]","HB CH AETNA HMO / PPO","291.89","58.3","","28.02","15.31","28.02","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.36","53","","79.50","79.50","79.50","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.55","44.45","","25.51","25.51","25.51","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","WELLPOINT [1015]","HB CH WELLPOINT","390.07","77.91","","135.65","59.07","274.09","13","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","500.67","375.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","296.90","59.3","","43.95","43.95","43.95","1 through 10","250.34","392.78","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","500.67","375.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.78","78.45","","57.66","15.03","149.03","11","250.34","392.78","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","AETNA [1001]","HB CH AETNA HMO / PPO","291.89","58.3","","48.90","46.54","48.90","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.36","53","","91.65","91.65","91.65","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","290.39","58","","51.23","51.23","51.23","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","312.92","62.5","","65.12","36.89","65.12","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","365.49","73","","46.29","46.29","46.29","1 through 10","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","WELLPOINT [1015]","HB CH WELLPOINT","390.07","77.91","","64.65","45.40","120.92","18","222.55","390.07","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","500.67","375.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.78","78.45","","276.77","63.10","312.43","11","250.34","392.78","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","AETNA [1001]","HB CH AETNA HMO / PPO","268.82","58.3","","48.90","46.54","48.90","1 through 10","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.38","53","","91.65","91.65","91.65","1 through 10","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","267.44","58","","51.23","51.23","51.23","1 through 10","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","288.19","62.5","","65.12","36.89","65.12","1 through 10","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","336.60","73","","46.29","46.29","46.29","1 through 10","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","WELLPOINT [1015]","HB CH WELLPOINT","359.24","77.91","","64.65","45.40","120.92","18","204.96","359.24","percent of total billed charges",""
"SHEATH UROLOGICAL 9.5FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016944","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","461.10","345.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.73","78.45","","276.77","63.10","312.43","11","230.55","361.73","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1530.90","1160.93","1884.08","89","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","5253.92","5253.92","5253.92","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","904.80","58","","12181.47","12181.47","12181.47","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","975.00","62.5","","1350.68","1350.68","1350.68","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.42","44.45","","1910.74","891.94","1910.74","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","1829.79","1561.50","2617.12","88","693.42","1215.4","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1359.46","1201.30","1689.00","61","780","1223.82","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","925.08","59.3","","1718.92","1718.92","1718.92","1 through 10","780","1223.82","percent of total billed charges",""
"SHOULDER 38MM SHORT EQUINOXE ALPHA","SUP-ITM-10195085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","1910.74","1019.06","2344.84","74","780","1223.82","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","AETNA [1001]","HB CH AETNA HMO / PPO","773.06","58.3","","1530.90","1160.93","1884.08","89","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","702.78","53","","5253.92","5253.92","5253.92","1 through 10","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","769.08","58","","12181.47","12181.47","12181.47","1 through 10","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","828.75","62.5","","1350.68","1350.68","1350.68","1 through 10","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","589.41","44.45","","1910.74","891.94","1910.74","1 through 10","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","both","","","1326.00","994.50","WELLPOINT [1015]","HB CH WELLPOINT","1033.09","77.91","","1829.79","1561.50","2617.12","88","589.41","1033.09","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","786.32","59.3","","1359.46","1201.30","1689.00","61","663","1040.25","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","786.32","59.3","","1718.92","1718.92","1718.92","1 through 10","663","1040.25","percent of total billed charges",""
"SHOULDER 41MMX15 AEQUALIS COBALT","SUP-ITM-10006247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1040.25","78.45","","1910.74","1019.06","2344.84","74","663","1040.25","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"SHOULDER 43X16MM AEQUALIS ASCEND FLEXIABLE TITANIUM OFFSET LOW","SUP-ITM-10136065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","AETNA [1001]","HB CH AETNA HMO / PPO","954.95","58.3","","1530.90","1160.93","1884.08","89","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","868.14","53","","5253.92","5253.92","5253.92","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","950.04","58","","12181.47","12181.47","12181.47","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1023.75","62.5","","1350.68","1350.68","1350.68","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.09","44.45","","1910.74","891.94","1910.74","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","WELLPOINT [1015]","HB CH WELLPOINT","1276.17","77.91","","1829.79","1561.50","2617.12","88","728.09","1276.17","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","971.33","59.3","","1359.46","1201.30","1689.00","61","819","1285.01","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","971.33","59.3","","1718.92","1718.92","1718.92","1 through 10","819","1285.01","percent of total billed charges",""
"SHOULDER 46X21 50MM COMPREHENSIVE VERSA DIAL","SUP-ITM-10113691","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1285.01","78.45","","1910.74","1019.06","2344.84","74","819","1285.01","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","AETNA [1001]","HB CH AETNA HMO / PPO","954.95","58.3","","1530.90","1160.93","1884.08","89","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","868.14","53","","5253.92","5253.92","5253.92","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","950.04","58","","12181.47","12181.47","12181.47","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1023.75","62.5","","1350.68","1350.68","1350.68","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.09","44.45","","1910.74","891.94","1910.74","1 through 10","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","WELLPOINT [1015]","HB CH WELLPOINT","1276.17","77.91","","1829.79","1561.50","2617.12","88","728.09","1276.17","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","971.33","59.3","","1359.46","1201.30","1689.00","61","819","1285.01","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","971.33","59.3","","1718.92","1718.92","1718.92","1 through 10","819","1285.01","percent of total billed charges",""
"SHOULDER 54X21 64MM VERSA DIAL VARIABLE OFFSET","SUP-ITM-10113687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1285.01","78.45","","1910.74","1019.06","2344.84","74","819","1285.01","percent of total billed charges",""
"Shoulder And Elbow Joint Replacement,MINOR","322","DRG","","","","","","","","inpatient","","","73893.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46716.52","","Standard inlier is a Case rate ($46,716.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $56,262, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,631.21) for the length of stay and the standard reimbursement.","44593.03","44593.03","44593.03","1 through 10","13467.42","46716.52","case rate",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1530.90","1160.93","1884.08","89","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","5253.92","5253.92","5253.92","1 through 10","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2009.70","58","","12181.47","12181.47","12181.47","1 through 10","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2165.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1540.19","44.45","","1910.74","891.94","1910.74","1 through 10","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","1829.79","1561.50","2617.12","88","1540.19","2699.58","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1359.46","1201.30","1689.00","61","1732.5","2718.29","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1732.5","2718.29","percent of total billed charges",""
"SHOULDER AUGMENT SZ 5 RT GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","1910.74","1019.06","2344.84","74","1732.5","2718.29","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","1530.90","1160.93","1884.08","89","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2332.00","53","","5253.92","5253.92","5253.92","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","12181.47","12181.47","12181.47","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","1910.74","891.94","1910.74","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","1829.79","1561.50","2617.12","88","1955.8","3428.04","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","1359.46","1201.30","1689.00","61","2200","3451.8","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2609.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2200","3451.8","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT","SUP-ITM-10275306","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","1910.74","1019.06","2344.84","74","2200","3451.8","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1530.90","1160.93","1884.08","89","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","5253.92","5253.92","5253.92","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1955.83","58","","12181.47","12181.47","12181.47","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2107.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","1910.74","891.94","1910.74","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","1829.79","1561.50","2617.12","88","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1359.46","1201.30","1689.00","61","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","1910.74","1019.06","2344.84","74","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1530.90","1160.93","1884.08","89","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","5253.92","5253.92","5253.92","1 through 10","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3132.00","58","","12181.47","12181.47","12181.47","1 through 10","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3375.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2400.30","44.45","","1910.74","891.94","1910.74","1 through 10","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","1829.79","1561.50","2617.12","88","2400.3","4207.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1359.46","1201.30","1689.00","61","2700","4236.3","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1718.92","1718.92","1718.92","1 through 10","2700","4236.3","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","1910.74","1019.06","2344.84","74","2700","4236.3","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1530.90","1160.93","1884.08","89","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","5253.92","5253.92","5253.92","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2283.75","58","","12181.47","12181.47","12181.47","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2460.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.22","44.45","","1910.74","891.94","1910.74","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","1829.79","1561.50","2617.12","88","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1359.46","1201.30","1689.00","61","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1718.92","1718.92","1718.92","1 through 10","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","1910.74","1019.06","2344.84","74","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","AETNA [1001]","HB CH AETNA HMO / PPO","2024.69","58.3","","1530.90","1160.93","1884.08","89","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1840.63","53","","5253.92","5253.92","5253.92","1 through 10","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2014.27","58","","12181.47","12181.47","12181.47","1 through 10","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2170.55","62.5","","1350.68","1350.68","1350.68","1 through 10","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1543.70","44.45","","1910.74","891.94","1910.74","1 through 10","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","both","","","3472.88","2604.66","WELLPOINT [1015]","HB CH WELLPOINT","2705.72","77.91","","1829.79","1561.50","2617.12","88","1543.7","2705.72","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3472.88","2604.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2059.42","59.3","","1359.46","1201.30","1689.00","61","1736.44","2724.47","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3472.88","2604.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2059.42","59.3","","1718.92","1718.92","1718.92","1 through 10","1736.44","2724.47","percent of total billed charges",""
"SHOULDER BASEPLATE 26X30MM REVERSE PS COATED","SUP-ITM-10207519","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3472.88","2604.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2724.47","78.45","","1910.74","1019.06","2344.84","74","1736.44","2724.47","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1530.90","1160.93","1884.08","89","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","5253.92","5253.92","5253.92","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2283.75","58","","12181.47","12181.47","12181.47","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2460.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.22","44.45","","1910.74","891.94","1910.74","1 through 10","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","1829.79","1561.50","2617.12","88","1750.22","3067.71","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1359.46","1201.30","1689.00","61","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1718.92","1718.92","1718.92","1 through 10","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","1910.74","1019.06","2344.84","74","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","1530.90","1160.93","1884.08","89","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","5253.92","5253.92","5253.92","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1957.50","58","","12181.47","12181.47","12181.47","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2109.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","1910.74","891.94","1910.74","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","1829.79","1561.50","2617.12","88","1500.19","2629.46","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1359.46","1201.30","1689.00","61","1687.5","2647.69","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1718.92","1718.92","1718.92","1 through 10","1687.5","2647.69","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","1910.74","1019.06","2344.84","74","1687.5","2647.69","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1530.90","1160.93","1884.08","89","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","5253.92","5253.92","5253.92","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1955.83","58","","12181.47","12181.47","12181.47","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2107.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","1910.74","891.94","1910.74","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","1829.79","1561.50","2617.12","88","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1359.46","1201.30","1689.00","61","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","1910.74","1019.06","2344.84","74","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","AETNA [1001]","HB CH AETNA HMO / PPO","2595.81","58.3","","1530.90","1160.93","1884.08","89","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2359.83","53","","5253.92","5253.92","5253.92","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2582.45","58","","12181.47","12181.47","12181.47","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2782.81","62.5","","1350.68","1350.68","1350.68","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1979.14","44.45","","1910.74","891.94","1910.74","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","WELLPOINT [1015]","HB CH WELLPOINT","3468.94","77.91","","1829.79","1561.50","2617.12","88","1979.14","3468.94","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2640.33","59.3","","1359.46","1201.30","1689.00","61","2226.25","3492.99","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2640.33","59.3","","1718.92","1718.92","1718.92","1 through 10","2226.25","3492.99","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3492.99","78.45","","1910.74","1019.06","2344.84","74","2226.25","3492.99","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1530.90","1160.93","1884.08","89","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","5253.92","5253.92","5253.92","1 through 10","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1914.00","58","","12181.47","12181.47","12181.47","1 through 10","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","1910.74","891.94","1910.74","1 through 10","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","1829.79","1561.50","2617.12","88","1466.85","2571.03","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1359.46","1201.30","1689.00","61","1650","2588.85","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1718.92","1718.92","1718.92","1 through 10","1650","2588.85","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","1910.74","1019.06","2344.84","74","1650","2588.85","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","464.71","67.87","1012.10","221","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1965.95","58.3","","293.04","293.04","293.04","11","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","983.89","983.89","983.89","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1955.83","58","","677.18","677.18","677.18","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2107.58","62.5","","46.58","46.58","46.58","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","747.15","747.15","747.15","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","1141.67","481.21","1141.67","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","76.54","76.54","76.54","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","273.64","94.28","1367.51","138","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","720.78","230.14","2010.94","427","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1999.67","59.3","","344.45","344.45","344.45","1 through 10","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","1120.13","1120.13","1120.13","1 through 10","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","456.17","105.33","1284.66","242","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1530.90","1160.93","1884.08","89","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","5253.92","5253.92","5253.92","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1955.83","58","","12181.47","12181.47","12181.47","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2107.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","1910.74","891.94","1910.74","1 through 10","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","1829.79","1561.50","2617.12","88","1498.91","2627.22","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1359.46","1201.30","1689.00","61","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1718.92","1718.92","1718.92","1 through 10","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","1910.74","1019.06","2344.84","74","1686.06","2645.43","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","1530.90","1160.93","1884.08","89","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","5253.92","5253.92","5253.92","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1957.50","58","","12181.47","12181.47","12181.47","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2109.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1500.19","44.45","","1910.74","891.94","1910.74","1 through 10","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","1829.79","1561.50","2617.12","88","1500.19","2629.46","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1359.46","1201.30","1689.00","61","1687.5","2647.69","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1718.92","1718.92","1718.92","1 through 10","1687.5","2647.69","percent of total billed charges",""
"SHOULDER CAGE SM AUGMENTED EQUINOXE LEFT","SUP-ITM-10195009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","1910.74","1019.06","2344.84","74","1687.5","2647.69","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1530.90","1160.93","1884.08","89","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","5253.92","5253.92","5253.92","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","12181.47","12181.47","12181.47","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1910.74","891.94","1910.74","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","1829.79","1561.50","2617.12","88","1610.87","2823.46","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1359.46","1201.30","1689.00","61","1812","2843.03","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1718.92","1718.92","1718.92","1 through 10","1812","2843.03","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1910.74","1019.06","2344.84","74","1812","2843.03","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1530.90","1160.93","1884.08","89","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1203.63","53","","5253.92","5253.92","5253.92","1 through 10","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1317.18","58","","12181.47","12181.47","12181.47","1 through 10","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1419.38","62.5","","1350.68","1350.68","1350.68","1 through 10","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.46","44.45","","1910.74","891.94","1910.74","1 through 10","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","1829.79","1561.50","2617.12","88","1009.46","1769.34","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1359.46","1201.30","1689.00","61","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1718.92","1718.92","1718.92","1 through 10","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID","SUP-ITM-10028056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","1910.74","1019.06","2344.84","74","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1530.90","1160.93","1884.08","89","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","5253.92","5253.92","5253.92","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","12181.47","12181.47","12181.47","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","1350.68","1350.68","1350.68","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1910.74","891.94","1910.74","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","1829.79","1561.50","2617.12","88","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1359.46","1201.30","1689.00","61","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","1718.92","1718.92","1718.92","1 through 10","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1910.74","1019.06","2344.84","74","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1530.90","1160.93","1884.08","89","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","5253.92","5253.92","5253.92","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","870.00","58","","12181.47","12181.47","12181.47","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","937.50","62.5","","1350.68","1350.68","1350.68","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","1910.74","891.94","1910.74","1 through 10","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","1829.79","1561.50","2617.12","88","666.75","1168.65","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1359.46","1201.30","1689.00","61","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","889.50","59.3","","1718.92","1718.92","1718.92","1 through 10","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1910.74","1019.06","2344.84","74","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","1530.90","1160.93","1884.08","89","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","5253.92","5253.92","5253.92","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8.70","58","","12181.47","12181.47","12181.47","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9.38","62.5","","1350.68","1350.68","1350.68","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.67","44.45","","1910.74","891.94","1910.74","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","1829.79","1561.50","2617.12","88","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","1359.46","1201.30","1689.00","61","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","8.90","59.3","","1718.92","1718.92","1718.92","1 through 10","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","1910.74","1019.06","2344.84","74","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","1530.90","1160.93","1884.08","89","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","5253.92","5253.92","5253.92","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","8.70","58","","12181.47","12181.47","12181.47","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9.38","62.5","","1350.68","1350.68","1350.68","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.67","44.45","","1910.74","891.94","1910.74","1 through 10","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","1829.79","1561.50","2617.12","88","6.67","11.69","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","1359.46","1201.30","1689.00","61","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","8.90","59.3","","1718.92","1718.92","1718.92","1 through 10","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT LG GLENOID CLEAT","SUP-ITM-10174756","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","1910.74","1019.06","2344.84","74","7.5","11.77","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1530.90","1160.93","1884.08","89","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","5253.92","5253.92","5253.92","1 through 10","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","12181.47","12181.47","12181.47","1 through 10","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","1350.68","1350.68","1350.68","1 through 10","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1910.74","891.94","1910.74","1 through 10","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","1829.79","1561.50","2617.12","88","840.11","1472.5","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1359.46","1201.30","1689.00","61","945","1482.71","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1718.92","1718.92","1718.92","1 through 10","945","1482.71","percent of total billed charges",""
"SHOULDER COMPONENT SZ 3 GLENOID WITH 4 PEG MODULAR ALLIANCE","SUP-ITM-10281969","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1910.74","1019.06","2344.84","74","945","1482.71","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","AETNA [1001]","HB CH AETNA HMO / PPO","2046.33","58.3","","1530.90","1160.93","1884.08","89","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1860.30","53","","5253.92","5253.92","5253.92","1 through 10","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2035.80","58","","12181.47","12181.47","12181.47","1 through 10","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2193.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.20","44.45","","1910.74","891.94","1910.74","1 through 10","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","WELLPOINT [1015]","HB CH WELLPOINT","2734.64","77.91","","1829.79","1561.50","2617.12","88","1560.2","2734.64","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.43","59.3","","1359.46","1201.30","1689.00","61","1755","2753.6","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2081.43","59.3","","1718.92","1718.92","1718.92","1 through 10","1755","2753.6","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.60","78.45","","1910.74","1019.06","2344.84","74","1755","2753.6","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","AETNA [1001]","HB CH AETNA HMO / PPO","1803.22","58.3","","1530.90","1160.93","1884.08","89","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1639.29","53","","5253.92","5253.92","5253.92","1 through 10","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1793.94","58","","12181.47","12181.47","12181.47","1 through 10","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1933.13","62.5","","1350.68","1350.68","1350.68","1 through 10","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1374.84","44.45","","1910.74","891.94","1910.74","1 through 10","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","WELLPOINT [1015]","HB CH WELLPOINT","2409.76","77.91","","1829.79","1561.50","2617.12","88","1374.84","2409.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3093.00","2319.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1834.15","59.3","","1359.46","1201.30","1689.00","61","1546.5","2426.46","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3093.00","2319.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1834.15","59.3","","1718.92","1718.92","1718.92","1 through 10","1546.5","2426.46","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3093.00","2319.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2426.46","78.45","","1910.74","1019.06","2344.84","74","1546.5","2426.46","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","AETNA [1001]","HB CH AETNA HMO / PPO","2046.19","58.3","","1530.90","1160.93","1884.08","89","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1860.17","53","","5253.92","5253.92","5253.92","1 through 10","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2035.66","58","","12181.47","12181.47","12181.47","1 through 10","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2193.60","62.5","","1350.68","1350.68","1350.68","1 through 10","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.09","44.45","","1910.74","891.94","1910.74","1 through 10","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","WELLPOINT [1015]","HB CH WELLPOINT","2734.45","77.91","","1829.79","1561.50","2617.12","88","1560.09","2734.45","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3509.76","2632.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.29","59.3","","1359.46","1201.30","1689.00","61","1754.88","2753.41","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3509.76","2632.32","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2081.29","59.3","","1718.92","1718.92","1718.92","1 through 10","1754.88","2753.41","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3509.76","2632.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.41","78.45","","1910.74","1019.06","2344.84","74","1754.88","2753.41","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1530.90","1160.93","1884.08","89","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","5253.92","5253.92","5253.92","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","12181.47","12181.47","12181.47","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1910.74","891.94","1910.74","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","1829.79","1561.50","2617.12","88","1610.87","2823.46","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1359.46","1201.30","1689.00","61","1812","2843.03","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1718.92","1718.92","1718.92","1 through 10","1812","2843.03","percent of total billed charges",""
"SHOULDER GLENOID SZ 32MM HEAD RSP REVERSE RETAINING SCREW NEUTRAL","SUP-ITM-10207518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1910.74","1019.06","2344.84","74","1812","2843.03","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1530.90","1160.93","1884.08","89","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","5253.92","5253.92","5253.92","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1995.74","58","","12181.47","12181.47","12181.47","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2150.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.49","44.45","","1910.74","891.94","1910.74","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","1829.79","1561.50","2617.12","88","1529.49","2680.83","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1359.46","1201.30","1689.00","61","1720.47","2699.41","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1718.92","1718.92","1718.92","1 through 10","1720.47","2699.41","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36 4 LAT/24","SUP-ITM-10233503","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","1910.74","1019.06","2344.84","74","1720.47","2699.41","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","AETNA [1001]","HB CH AETNA HMO / PPO","2218.43","58.3","","1530.90","1160.93","1884.08","89","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2016.76","53","","5253.92","5253.92","5253.92","1 through 10","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2207.02","58","","12181.47","12181.47","12181.47","1 through 10","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2378.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1691.41","44.45","","1910.74","891.94","1910.74","1 through 10","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","WELLPOINT [1015]","HB CH WELLPOINT","2964.63","77.91","","1829.79","1561.50","2617.12","88","1691.41","2964.63","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1359.46","1201.30","1689.00","61","1902.6","2985.18","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1718.92","1718.92","1718.92","1 through 10","1902.6","2985.18","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2985.18","78.45","","1910.74","1019.06","2344.84","74","1902.6","2985.18","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","AETNA [1001]","HB CH AETNA HMO / PPO","1931.19","58.3","","1530.90","1160.93","1884.08","89","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1755.63","53","","5253.92","5253.92","5253.92","1 through 10","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1921.25","58","","12181.47","12181.47","12181.47","1 through 10","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2070.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1472.41","44.45","","1910.74","891.94","1910.74","1 through 10","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","WELLPOINT [1015]","HB CH WELLPOINT","2580.77","77.91","","1829.79","1561.50","2617.12","88","1472.41","2580.77","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1964.31","59.3","","1359.46","1201.30","1689.00","61","1656.25","2598.66","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1964.31","59.3","","1718.92","1718.92","1718.92","1 through 10","1656.25","2598.66","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2598.66","78.45","","1910.74","1019.06","2344.84","74","1656.25","2598.66","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","AETNA [1001]","HB CH AETNA HMO / PPO","3789.50","58.3","","1530.90","1160.93","1884.08","89","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3445.00","53","","5253.92","5253.92","5253.92","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3770.00","58","","12181.47","12181.47","12181.47","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2889.25","44.45","","1910.74","891.94","1910.74","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB CH WELLPOINT","5064.15","77.91","","1829.79","1561.50","2617.12","88","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1359.46","1201.30","1689.00","61","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1718.92","1718.92","1718.92","1 through 10","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 30X5.0MM COMPONENT FIXATION ARTICULAR RESURFACING OFFSET COBALT","SUP-ITM-10028002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5099.25","78.45","","1910.74","1019.06","2344.84","74","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","AETNA [1001]","HB CH AETNA HMO / PPO","3789.50","58.3","","1530.90","1160.93","1884.08","89","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3445.00","53","","5253.92","5253.92","5253.92","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3770.00","58","","12181.47","12181.47","12181.47","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4062.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2889.25","44.45","","1910.74","891.94","1910.74","1 through 10","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB CH WELLPOINT","5064.15","77.91","","1829.79","1561.50","2617.12","88","2889.25","5064.15","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1359.46","1201.30","1689.00","61","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1718.92","1718.92","1718.92","1 through 10","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 35MM 7.0XART COMP HUMERAL 05B2","SUP-ITM-10021948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5099.25","78.45","","1910.74","1019.06","2344.84","74","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1530.90","1160.93","1884.08","89","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","5253.92","5253.92","5253.92","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1995.74","58","","12181.47","12181.47","12181.47","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2150.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.49","44.45","","1910.74","891.94","1910.74","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","1829.79","1561.50","2617.12","88","1529.49","2680.83","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1359.46","1201.30","1689.00","61","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1718.92","1718.92","1718.92","1 through 10","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","1910.74","1019.06","2344.84","74","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","AETNA [1001]","HB CH AETNA HMO / PPO","3036.66","58.3","","1530.90","1160.93","1884.08","89","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2760.60","53","","5253.92","5253.92","5253.92","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3021.03","58","","12181.47","12181.47","12181.47","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3255.43","62.5","","1350.68","1350.68","1350.68","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2315.26","44.45","","1910.74","891.94","1910.74","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","WELLPOINT [1015]","HB CH WELLPOINT","4058.08","77.91","","1829.79","1561.50","2617.12","88","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","3088.75","59.3","","1359.46","1201.30","1689.00","61","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3088.75","59.3","","1718.92","1718.92","1718.92","1 through 10","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4086.21","78.45","","1910.74","1019.06","2344.84","74","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","AETNA [1001]","HB CH AETNA HMO / PPO","3036.66","58.3","","1530.90","1160.93","1884.08","89","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2760.60","53","","5253.92","5253.92","5253.92","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3021.03","58","","12181.47","12181.47","12181.47","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3255.43","62.5","","1350.68","1350.68","1350.68","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2315.26","44.45","","1910.74","891.94","1910.74","1 through 10","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","WELLPOINT [1015]","HB CH WELLPOINT","4058.08","77.91","","1829.79","1561.50","2617.12","88","2315.26","4058.08","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","3088.75","59.3","","1359.46","1201.30","1689.00","61","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3088.75","59.3","","1718.92","1718.92","1718.92","1 through 10","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 16MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4086.21","78.45","","1910.74","1019.06","2344.84","74","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1530.90","1160.93","1884.08","89","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","5253.92","5253.92","5253.92","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","904.80","58","","12181.47","12181.47","12181.47","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","975.00","62.5","","1350.68","1350.68","1350.68","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.42","44.45","","1910.74","891.94","1910.74","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","1829.79","1561.50","2617.12","88","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1359.46","1201.30","1689.00","61","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","925.08","59.3","","1718.92","1718.92","1718.92","1 through 10","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 16X42MM HEAD ALTIVATE ANATOMIC OFFSET","SUP-ITM-10207533","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","1910.74","1019.06","2344.84","74","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1530.90","1160.93","1884.08","89","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","5253.92","5253.92","5253.92","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","904.80","58","","12181.47","12181.47","12181.47","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","975.00","62.5","","1350.68","1350.68","1350.68","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.42","44.45","","1910.74","891.94","1910.74","1 through 10","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","1829.79","1561.50","2617.12","88","693.42","1215.4","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1359.46","1201.30","1689.00","61","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","925.08","59.3","","1718.92","1718.92","1718.92","1 through 10","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 18X50MM HEAD ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207527","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","1910.74","1019.06","2344.84","74","780","1223.82","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB CH AETNA HMO / PPO","1442.93","58.3","","1530.90","1160.93","1884.08","89","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1311.75","53","","5253.92","5253.92","5253.92","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1435.50","58","","12181.47","12181.47","12181.47","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1546.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1100.14","44.45","","1910.74","891.94","1910.74","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB CH WELLPOINT","1928.27","77.91","","1829.79","1561.50","2617.12","88","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1359.46","1201.30","1689.00","61","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1718.92","1718.92","1718.92","1 through 10","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 32MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1941.64","78.45","","1910.74","1019.06","2344.84","74","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB CH AETNA HMO / PPO","1442.93","58.3","","1530.90","1160.93","1884.08","89","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1311.75","53","","5253.92","5253.92","5253.92","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1435.50","58","","12181.47","12181.47","12181.47","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1546.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1100.14","44.45","","1910.74","891.94","1910.74","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB CH WELLPOINT","1928.27","77.91","","1829.79","1561.50","2617.12","88","1100.14","1928.27","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1359.46","1201.30","1689.00","61","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1718.92","1718.92","1718.92","1 through 10","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 32MM PLUS 4MM INSERT SOCKET HXE-PLUS REVERSE RSP STANDARD","SUP-ITM-10207591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1941.64","78.45","","1910.74","1019.06","2344.84","74","1237.5","1941.64","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","AETNA [1001]","HB CH AETNA HMO / PPO","5693.05","58.3","","1530.90","1160.93","1884.08","89","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5175.50","53","","5253.92","5253.92","5253.92","1 through 10","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5663.76","58","","12181.47","12181.47","12181.47","1 through 10","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6103.19","62.5","","1350.68","1350.68","1350.68","1 through 10","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4340.59","44.45","","1910.74","891.94","1910.74","1 through 10","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","WELLPOINT [1015]","HB CH WELLPOINT","7607.99","77.91","","1829.79","1561.50","2617.12","88","4340.59","7607.99","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","5790.70","59.3","","1359.46","1201.30","1689.00","61","4882.55","7660.72","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5790.70","59.3","","1718.92","1718.92","1718.92","1 through 10","4882.55","7660.72","percent of total billed charges",""
"SHOULDER HUMERAL 8X108MM STEM ALTIVATE REVERSE PRIMARY","SUP-ITM-10208216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7660.72","78.45","","1910.74","1019.06","2344.84","74","4882.55","7660.72","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","1530.90","1160.93","1884.08","89","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","5253.92","5253.92","5253.92","1 through 10","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","652.50","58","","12181.47","12181.47","12181.47","1 through 10","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","703.13","62.5","","1350.68","1350.68","1350.68","1 through 10","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","1910.74","891.94","1910.74","1 through 10","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","1829.79","1561.50","2617.12","88","500.06","876.49","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","1359.46","1201.30","1689.00","61","562.5","882.56","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","667.13","59.3","","1718.92","1718.92","1718.92","1 through 10","562.5","882.56","percent of total billed charges",""
"SHOULDER HUMERAL NECK ALTIVATE ANATOMIC NEUTRAL","SUP-ITM-10207806","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","1910.74","1019.06","2344.84","74","562.5","882.56","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1530.90","1160.93","1884.08","89","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","5253.92","5253.92","5253.92","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2101.92","58","","12181.47","12181.47","12181.47","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2265.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.87","44.45","","1910.74","891.94","1910.74","1 through 10","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","1829.79","1561.50","2617.12","88","1610.87","2823.46","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1359.46","1201.30","1689.00","61","1812","2843.03","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1718.92","1718.92","1718.92","1 through 10","1812","2843.03","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","1910.74","1019.06","2344.84","74","1812","2843.03","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","AETNA [1001]","HB CH AETNA HMO / PPO","2215.40","58.3","","1530.90","1160.93","1884.08","89","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2014.00","53","","5253.92","5253.92","5253.92","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2204.00","58","","12181.47","12181.47","12181.47","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2375.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.10","44.45","","1910.74","891.94","1910.74","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","WELLPOINT [1015]","HB CH WELLPOINT","2960.58","77.91","","1829.79","1561.50","2617.12","88","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1359.46","1201.30","1689.00","61","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1718.92","1718.92","1718.92","1 through 10","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2981.10","78.45","","1910.74","1019.06","2344.84","74","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","AETNA [1001]","HB CH AETNA HMO / PPO","2215.40","58.3","","1530.90","1160.93","1884.08","89","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2014.00","53","","5253.92","5253.92","5253.92","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2204.00","58","","12181.47","12181.47","12181.47","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2375.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.10","44.45","","1910.74","891.94","1910.74","1 through 10","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","WELLPOINT [1015]","HB CH WELLPOINT","2960.58","77.91","","1829.79","1561.50","2617.12","88","1689.1","2960.58","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1359.46","1201.30","1689.00","61","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1718.92","1718.92","1718.92","1 through 10","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2981.10","78.45","","1910.74","1019.06","2344.84","74","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","AETNA [1001]","HB CH AETNA HMO / PPO","1896.21","58.3","","1530.90","1160.93","1884.08","89","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1723.83","53","","5253.92","5253.92","5253.92","1 through 10","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1886.45","58","","12181.47","12181.47","12181.47","1 through 10","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2032.81","62.5","","1350.68","1350.68","1350.68","1 through 10","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1445.74","44.45","","1910.74","891.94","1910.74","1 through 10","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","WELLPOINT [1015]","HB CH WELLPOINT","2534.02","77.91","","1829.79","1561.50","2617.12","88","1445.74","2534.02","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3252.50","2439.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1928.73","59.3","","1359.46","1201.30","1689.00","61","1626.25","2551.59","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3252.50","2439.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1928.73","59.3","","1718.92","1718.92","1718.92","1 through 10","1626.25","2551.59","percent of total billed charges",""
"SHOULDER IMPLANT SZ 1 CENTERED XTEND REVERSE 145DEG EPIPHYSIS STEM CUP MODULAR POROCOAT","SUP-ITM-10274323","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3252.50","2439.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2551.59","78.45","","1910.74","1019.06","2344.84","74","1626.25","2551.59","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1530.90","1160.93","1884.08","89","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","5253.92","5253.92","5253.92","1 through 10","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1044.00","58","","12181.47","12181.47","12181.47","1 through 10","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1125.00","62.5","","1350.68","1350.68","1350.68","1 through 10","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","1910.74","891.94","1910.74","1 through 10","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","1829.79","1561.50","2617.12","88","800.1","1402.38","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1359.46","1201.30","1689.00","61","900","1412.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1718.92","1718.92","1718.92","1 through 10","900","1412.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","1910.74","1019.06","2344.84","74","900","1412.1","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB CH AETNA HMO / PPO","1442.93","58.3","","1530.90","1160.93","1884.08","89","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1311.75","53","","5253.92","5253.92","5253.92","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1435.50","58","","12181.47","12181.47","12181.47","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1546.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1100.14","44.45","","1910.74","891.94","1910.74","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB CH WELLPOINT","1928.27","77.91","","1829.79","1561.50","2617.12","88","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1359.46","1201.30","1689.00","61","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1718.92","1718.92","1718.92","1 through 10","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL NEUTRAL 4 EPLUS","SUP-ITM-10267652","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1941.64","78.45","","1910.74","1019.06","2344.84","74","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB CH AETNA HMO / PPO","1442.93","58.3","","1530.90","1160.93","1884.08","89","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1311.75","53","","5253.92","5253.92","5253.92","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1435.50","58","","12181.47","12181.47","12181.47","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1546.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1100.14","44.45","","1910.74","891.94","1910.74","1 through 10","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB CH WELLPOINT","1928.27","77.91","","1829.79","1561.50","2617.12","88","1100.14","1928.27","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1359.46","1201.30","1689.00","61","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1467.68","59.3","","1718.92","1718.92","1718.92","1 through 10","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 32MM AR SMALL SEMI CONSTRAINED 4 EPLUS","SUP-ITM-10267871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1941.64","78.45","","1910.74","1019.06","2344.84","74","1237.5","1941.64","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","AETNA [1001]","HB CH AETNA HMO / PPO","1932.65","58.3","","1530.90","1160.93","1884.08","89","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1756.95","53","","5253.92","5253.92","5253.92","1 through 10","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1922.70","58","","12181.47","12181.47","12181.47","1 through 10","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2071.88","62.5","","1350.68","1350.68","1350.68","1 through 10","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1473.52","44.45","","1910.74","891.94","1910.74","1 through 10","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","WELLPOINT [1015]","HB CH WELLPOINT","2582.72","77.91","","1829.79","1561.50","2617.12","88","1473.52","2582.72","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1359.46","1201.30","1689.00","61","1657.5","2600.62","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1718.92","1718.92","1718.92","1 through 10","1657.5","2600.62","percent of total billed charges",""
"SHOULDER INSERT 36X9.0MM AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10134854","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2600.62","78.45","","1910.74","1019.06","2344.84","74","1657.5","2600.62","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","AETNA [1001]","HB CH AETNA HMO / PPO","1163.52","58.3","","1530.90","1160.93","1884.08","89","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1057.75","53","","5253.92","5253.92","5253.92","1 through 10","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1157.54","58","","12181.47","12181.47","12181.47","1 through 10","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1247.34","62.5","","1350.68","1350.68","1350.68","1 through 10","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","887.11","44.45","","1910.74","891.94","1910.74","1 through 10","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","WELLPOINT [1015]","HB CH WELLPOINT","1554.89","77.91","","1829.79","1561.50","2617.12","88","887.11","1554.89","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1359.46","1201.30","1689.00","61","997.88","1565.67","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1718.92","1718.92","1718.92","1 through 10","997.88","1565.67","percent of total billed charges",""
"SHOULDER INSERT 42MM 3 LG PLUS UNIVERS REVERS IMPLANTABLE 04","SUP-ITM-10135361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1565.67","78.45","","1910.74","1019.06","2344.84","74","997.88","1565.67","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","AETNA [1001]","HB CH AETNA HMO / PPO","302.00","58.3","","464.71","67.87","1012.10","221","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","302.00","58.3","","293.04","293.04","293.04","11","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","274.55","53","","983.89","983.89","983.89","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","300.45","58","","677.18","677.18","677.18","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","323.76","62.5","","46.58","46.58","46.58","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","378.15","73","","747.15","747.15","747.15","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.26","44.45","","1141.67","481.21","1141.67","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.26","44.45","","76.54","76.54","76.54","1 through 10","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.01","388.51","WELLPOINT [1015]","HB CH WELLPOINT","403.58","77.91","","273.64","94.28","1367.51","138","230.26","403.58","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.01","388.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","307.18","59.3","","720.78","230.14","2010.94","427","259.01","406.38","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.01","388.51","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","307.18","59.3","","344.45","344.45","344.45","1 through 10","259.01","406.38","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.01","388.51","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","406.38","78.45","","1120.13","1120.13","1120.13","1 through 10","259.01","406.38","percent of total billed charges",""
"SHOULDER PIN BONE 3.2MMX9IN STEINMANN SS THREADED","SUP-ITM-10146790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.01","388.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","406.38","78.45","","456.17","105.33","1284.66","242","259.01","406.38","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1530.90","1160.93","1884.08","89","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","5253.92","5253.92","5253.92","1 through 10","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","12181.47","12181.47","12181.47","1 through 10","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","1350.68","1350.68","1350.68","1 through 10","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","1910.74","891.94","1910.74","1 through 10","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1829.79","1561.50","2617.12","88","933.45","1636.11","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1359.46","1201.30","1689.00","61","1050","1647.45","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1718.92","1718.92","1718.92","1 through 10","1050","1647.45","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1910.74","1019.06","2344.84","74","1050","1647.45","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","AETNA [1001]","HB CH AETNA HMO / PPO","2170.21","58.3","","464.71","67.87","1012.10","221","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2170.21","58.3","","293.04","293.04","293.04","11","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1972.92","53","","983.89","983.89","983.89","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2159.04","58","","677.18","677.18","677.18","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2326.56","62.5","","46.58","46.58","46.58","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2717.42","73","","747.15","747.15","747.15","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1654.65","44.45","","1141.67","481.21","1141.67","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1654.65","44.45","","76.54","76.54","76.54","1 through 10","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","WELLPOINT [1015]","HB CH WELLPOINT","2900.19","77.91","","273.64","94.28","1367.51","138","1654.65","2900.19","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2207.44","59.3","","720.78","230.14","2010.94","427","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2207.44","59.3","","344.45","344.45","344.45","1 through 10","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2920.29","78.45","","1120.13","1120.13","1120.13","1 through 10","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2920.29","78.45","","456.17","105.33","1284.66","242","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","AETNA [1001]","HB CH AETNA HMO / PPO","2009.21","58.3","","464.71","67.87","1012.10","221","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2009.21","58.3","","293.04","293.04","293.04","11","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1826.55","53","","983.89","983.89","983.89","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1998.87","58","","677.18","677.18","677.18","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2153.96","62.5","","46.58","46.58","46.58","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2515.82","73","","747.15","747.15","747.15","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.89","44.45","","1141.67","481.21","1141.67","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.89","44.45","","76.54","76.54","76.54","1 through 10","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","WELLPOINT [1015]","HB CH WELLPOINT","2685.04","77.91","","273.64","94.28","1367.51","138","1531.89","2685.04","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2043.67","59.3","","720.78","230.14","2010.94","427","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2043.67","59.3","","344.45","344.45","344.45","1 through 10","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2703.65","78.45","","1120.13","1120.13","1120.13","1 through 10","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2703.65","78.45","","456.17","105.33","1284.66","242","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","AETNA [1001]","HB CH AETNA HMO / PPO","2080.57","58.3","","464.71","67.87","1012.10","221","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2080.57","58.3","","293.04","293.04","293.04","11","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1891.43","53","","983.89","983.89","983.89","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2069.86","58","","677.18","677.18","677.18","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2230.46","62.5","","46.58","46.58","46.58","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2605.17","73","","747.15","747.15","747.15","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1586.30","44.45","","1141.67","481.21","1141.67","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1586.30","44.45","","76.54","76.54","76.54","1 through 10","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","WELLPOINT [1015]","HB CH WELLPOINT","2780.40","77.91","","273.64","94.28","1367.51","138","1586.3","2780.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","2116.26","59.3","","720.78","230.14","2010.94","427","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2116.26","59.3","","344.45","344.45","344.45","1 through 10","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2799.67","78.45","","1120.13","1120.13","1120.13","1 through 10","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2799.67","78.45","","456.17","105.33","1284.66","242","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","AETNA [1001]","HB CH AETNA HMO / PPO","2228.19","58.3","","464.71","67.87","1012.10","221","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2228.19","58.3","","293.04","293.04","293.04","11","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2025.63","53","","983.89","983.89","983.89","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2216.73","58","","677.18","677.18","677.18","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2388.71","62.5","","46.58","46.58","46.58","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2790.02","73","","747.15","747.15","747.15","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.85","44.45","","1141.67","481.21","1141.67","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.85","44.45","","76.54","76.54","76.54","1 through 10","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","3821.94","2866.45","WELLPOINT [1015]","HB CH WELLPOINT","2977.67","77.91","","273.64","94.28","1367.51","138","1698.85","2977.67","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3821.94","2866.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","2266.41","59.3","","720.78","230.14","2010.94","427","1910.97","2998.31","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3821.94","2866.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2266.41","59.3","","344.45","344.45","344.45","1 through 10","1910.97","2998.31","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3821.94","2866.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2998.31","78.45","","1120.13","1120.13","1120.13","1 through 10","1910.97","2998.31","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3821.94","2866.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2998.31","78.45","","456.17","105.33","1284.66","242","1910.97","2998.31","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1530.90","1160.93","1884.08","89","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","5253.92","5253.92","5253.92","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1995.74","58","","12181.47","12181.47","12181.47","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2150.58","62.5","","1350.68","1350.68","1350.68","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.49","44.45","","1910.74","891.94","1910.74","1 through 10","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","1829.79","1561.50","2617.12","88","1529.49","2680.83","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1359.46","1201.30","1689.00","61","1720.47","2699.41","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1718.92","1718.92","1718.92","1 through 10","1720.47","2699.41","percent of total billed charges",""
"SHOULDER PLATE 39MM 4 MED SPHERE GLENOID PLUS HEAD LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10133952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","1910.74","1019.06","2344.84","74","1720.47","2699.41","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","AETNA [1001]","HB CH AETNA HMO / PPO","2012.81","58.3","","464.71","67.87","1012.10","221","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2012.81","58.3","","293.04","293.04","293.04","11","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1829.83","53","","983.89","983.89","983.89","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2002.45","58","","677.18","677.18","677.18","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2157.81","62.5","","46.58","46.58","46.58","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2520.33","73","","747.15","747.15","747.15","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.64","44.45","","1141.67","481.21","1141.67","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.64","44.45","","76.54","76.54","76.54","1 through 10","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","WELLPOINT [1015]","HB CH WELLPOINT","2689.84","77.91","","273.64","94.28","1367.51","138","1534.64","2689.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2047.33","59.3","","720.78","230.14","2010.94","427","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2047.33","59.3","","344.45","344.45","344.45","1 through 10","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2708.49","78.45","","1120.13","1120.13","1120.13","1 through 10","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2708.49","78.45","","456.17","105.33","1284.66","242","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","AETNA [1001]","HB CH AETNA HMO / PPO","2595.81","58.3","","1530.90","1160.93","1884.08","89","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2359.83","53","","5253.92","5253.92","5253.92","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2582.45","58","","12181.47","12181.47","12181.47","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2782.81","62.5","","1350.68","1350.68","1350.68","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1979.14","44.45","","1910.74","891.94","1910.74","1 through 10","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4452.50","3339.37","WELLPOINT [1015]","HB CH WELLPOINT","3468.94","77.91","","1829.79","1561.50","2617.12","88","1979.14","3468.94","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2640.33","59.3","","1359.46","1201.30","1689.00","61","2226.25","3492.99","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2640.33","59.3","","1718.92","1718.92","1718.92","1 through 10","2226.25","3492.99","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4452.50","3339.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3492.99","78.45","","1910.74","1019.06","2344.84","74","2226.25","3492.99","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","464.71","67.87","1012.10","221","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","293.04","293.04","293.04","11","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","983.89","983.89","983.89","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","677.18","677.18","677.18","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","46.58","46.58","46.58","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","747.15","747.15","747.15","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1141.67","481.21","1141.67","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","76.54","76.54","76.54","1 through 10","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","273.64","94.28","1367.51","138","1233.49","2162","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","720.78","230.14","2010.94","427","1387.5","2176.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1645.58","59.3","","344.45","344.45","344.45","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","456.17","105.33","1284.66","242","1387.5","2176.99","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","AETNA [1001]","HB CH AETNA HMO / PPO","1285.52","58.3","","1530.90","1160.93","1884.08","89","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1168.65","53","","5253.92","5253.92","5253.92","1 through 10","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1278.90","58","","12181.47","12181.47","12181.47","1 through 10","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1378.13","62.5","","1350.68","1350.68","1350.68","1 through 10","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.12","44.45","","1910.74","891.94","1910.74","1 through 10","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB CH WELLPOINT","1717.92","77.91","","1829.79","1561.50","2617.12","88","980.12","1717.92","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1307.57","59.3","","1359.46","1201.30","1689.00","61","1102.5","1729.82","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1307.57","59.3","","1718.92","1718.92","1718.92","1 through 10","1102.5","1729.82","percent of total billed charges",""
"SHOULDER POST GLENOID MODULAR ALLIANCE TRABECULAR METAL","SUP-ITM-10281957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1729.82","78.45","","1910.74","1019.06","2344.84","74","1102.5","1729.82","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","1530.90","1160.93","1884.08","89","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","5253.92","5253.92","5253.92","1 through 10","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","739.50","58","","12181.47","12181.47","12181.47","1 through 10","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","796.88","62.5","","1350.68","1350.68","1350.68","1 through 10","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","1910.74","891.94","1910.74","1 through 10","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","1829.79","1561.50","2617.12","88","566.74","993.35","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","1359.46","1201.30","1689.00","61","637.5","1000.24","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","756.08","59.3","","1718.92","1718.92","1718.92","1 through 10","637.5","1000.24","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","1910.74","1019.06","2344.84","74","637.5","1000.24","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","AETNA [1001]","HB CH AETNA HMO / PPO","4104.32","58.3","","1530.90","1160.93","1884.08","89","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3731.20","53","","5253.92","5253.92","5253.92","1 through 10","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4083.20","58","","12181.47","12181.47","12181.47","1 through 10","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4400.00","62.5","","1350.68","1350.68","1350.68","1 through 10","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3129.28","44.45","","1910.74","891.94","1910.74","1 through 10","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","WELLPOINT [1015]","HB CH WELLPOINT","5484.86","77.91","","1829.79","1561.50","2617.12","88","3129.28","5484.86","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7040.00","5280.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4174.72","59.3","","1359.46","1201.30","1689.00","61","3520","5522.88","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7040.00","5280.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4174.72","59.3","","1718.92","1718.92","1718.92","1 through 10","3520","5522.88","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7040.00","5280.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5522.88","78.45","","1910.74","1019.06","2344.84","74","3520","5522.88","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","AETNA [1001]","HB CH AETNA HMO / PPO","2668.97","58.3","","1530.90","1160.93","1884.08","89","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2426.34","53","","5253.92","5253.92","5253.92","1 through 10","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2655.24","58","","12181.47","12181.47","12181.47","1 through 10","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2861.25","62.5","","1350.68","1350.68","1350.68","1 through 10","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2034.92","44.45","","1910.74","891.94","1910.74","1 through 10","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4578.00","3433.50","WELLPOINT [1015]","HB CH WELLPOINT","3566.72","77.91","","1829.79","1561.50","2617.12","88","2034.92","3566.72","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4578.00","3433.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2714.75","59.3","","1359.46","1201.30","1689.00","61","2289","3591.44","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4578.00","3433.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2714.75","59.3","","1718.92","1718.92","1718.92","1 through 10","2289","3591.44","percent of total billed charges",""
"SHOULDER SPACER 8.0X46 18 53MM MOLD STAGEONE STANDARD STEM","SUP-ITM-10148302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4578.00","3433.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3591.44","78.45","","1910.74","1019.06","2344.84","74","2289","3591.44","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1530.90","1160.93","1884.08","89","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","5253.92","5253.92","5253.92","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1740.00","58","","12181.47","12181.47","12181.47","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1875.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","1910.74","891.94","1910.74","1 through 10","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","1829.79","1561.50","2617.12","88","1333.5","2337.3","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1359.46","1201.30","1689.00","61","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1718.92","1718.92","1718.92","1 through 10","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","1910.74","1019.06","2344.84","74","1500","2353.5","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","AETNA [1001]","HB CH AETNA HMO / PPO","7681.61","58.3","","1530.90","1160.93","1884.08","89","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6983.28","53","","5253.92","5253.92","5253.92","1 through 10","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7642.08","58","","12181.47","12181.47","12181.47","1 through 10","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","8235.00","62.5","","1350.68","1350.68","1350.68","1 through 10","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5856.73","44.45","","1910.74","891.94","1910.74","1 through 10","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","13176.00","9882.00","WELLPOINT [1015]","HB CH WELLPOINT","10265.42","77.91","","1829.79","1561.50","2617.12","88","5856.73","10265.42","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13176.00","9882.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7813.37","59.3","","1359.46","1201.30","1689.00","61","6588","10336.57","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13176.00","9882.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7813.37","59.3","","1718.92","1718.92","1718.92","1 through 10","6588","10336.57","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13176.00","9882.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10336.57","78.45","","1910.74","1019.06","2344.84","74","6588","10336.57","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","AETNA [1001]","HB CH AETNA HMO / PPO","2257.38","58.3","","1530.90","1160.93","1884.08","89","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.16","53","","5253.92","5253.92","5253.92","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2245.76","58","","12181.47","12181.47","12181.47","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.10","44.45","","1910.74","891.94","1910.74","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","WELLPOINT [1015]","HB CH WELLPOINT","3016.68","77.91","","1829.79","1561.50","2617.12","88","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.10","59.3","","1359.46","1201.30","1689.00","61","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 12.5MM EQUINOXE PLATFORM FX CEMENTED RIGHT","SUP-ITM-10195132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3037.58","78.45","","1910.74","1019.06","2344.84","74","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","AETNA [1001]","HB CH AETNA HMO / PPO","2801.90","58.3","","1530.90","1160.93","1884.08","89","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2547.18","53","","5253.92","5253.92","5253.92","1 through 10","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2787.48","58","","12181.47","12181.47","12181.47","1 through 10","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3003.75","62.5","","1350.68","1350.68","1350.68","1 through 10","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2136.27","44.45","","1910.74","891.94","1910.74","1 through 10","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.00","3604.50","WELLPOINT [1015]","HB CH WELLPOINT","3744.35","77.91","","1829.79","1561.50","2617.12","88","2136.27","3744.35","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2849.96","59.3","","1359.46","1201.30","1689.00","61","2403","3770.31","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2849.96","59.3","","1718.92","1718.92","1718.92","1 through 10","2403","3770.31","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.00","3604.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3770.31","78.45","","1910.74","1019.06","2344.84","74","2403","3770.31","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1530.90","1160.93","1884.08","89","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","5253.92","5253.92","5253.92","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","12181.47","12181.47","12181.47","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1910.74","891.94","1910.74","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","1829.79","1561.50","2617.12","88","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1359.46","1201.30","1689.00","61","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1718.92","1718.92","1718.92","1 through 10","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1910.74","1019.06","2344.84","74","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","AETNA [1001]","HB CH AETNA HMO / PPO","2257.38","58.3","","1530.90","1160.93","1884.08","89","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.16","53","","5253.92","5253.92","5253.92","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2245.76","58","","12181.47","12181.47","12181.47","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2420.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.10","44.45","","1910.74","891.94","1910.74","1 through 10","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3872.00","2904.00","WELLPOINT [1015]","HB CH WELLPOINT","3016.68","77.91","","1829.79","1561.50","2617.12","88","1721.1","3016.68","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.10","59.3","","1359.46","1201.30","1689.00","61","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2296.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 6.5MM PLATFORM FX EQUINOXE RIGHT","SUP-ITM-10195134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3037.58","78.45","","1910.74","1019.06","2344.84","74","1936","3037.58","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1530.90","1160.93","1884.08","89","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","5253.92","5253.92","5253.92","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","12181.47","12181.47","12181.47","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1910.74","891.94","1910.74","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","1829.79","1561.50","2617.12","88","1866.9","3272.22","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1359.46","1201.30","1689.00","61","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1718.92","1718.92","1718.92","1 through 10","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL UNIVERS II","SUP-ITM-10135835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1910.74","1019.06","2344.84","74","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","AETNA [1001]","HB CH AETNA HMO / PPO","2365.52","58.3","","1530.90","1160.93","1884.08","89","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2150.48","53","","5253.92","5253.92","5253.92","1 through 10","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2353.35","58","","12181.47","12181.47","12181.47","1 through 10","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2535.94","62.5","","1350.68","1350.68","1350.68","1 through 10","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1803.56","44.45","","1910.74","891.94","1910.74","1 through 10","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","WELLPOINT [1015]","HB CH WELLPOINT","3161.20","77.91","","1829.79","1561.50","2617.12","88","1803.56","3161.2","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2406.10","59.3","","1359.46","1201.30","1689.00","61","2028.75","3183.11","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2406.10","59.3","","1718.92","1718.92","1718.92","1 through 10","2028.75","3183.11","percent of total billed charges",""
"SHOULDER STEM 8MM HUMERAL CEMENTED","SUP-ITM-10156486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3183.11","78.45","","1910.74","1019.06","2344.84","74","2028.75","3183.11","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","AETNA [1001]","HB CH AETNA HMO / PPO","5247.00","58.3","","1530.90","1160.93","1884.08","89","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4770.00","53","","5253.92","5253.92","5253.92","1 through 10","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5220.00","58","","12181.47","12181.47","12181.47","1 through 10","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5625.00","62.5","","1350.68","1350.68","1350.68","1 through 10","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4000.50","44.45","","1910.74","891.94","1910.74","1 through 10","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","WELLPOINT [1015]","HB CH WELLPOINT","7011.90","77.91","","1829.79","1561.50","2617.12","88","4000.5","7011.9","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5337.00","59.3","","1359.46","1201.30","1689.00","61","4500","7060.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5337.00","59.3","","1718.92","1718.92","1718.92","1 through 10","4500","7060.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7060.50","78.45","","1910.74","1019.06","2344.84","74","4500","7060.5","percent of total billed charges",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","","","","inpatient","","","47642.45","35731.84","MEDICARE [2001]","HB NWH MEDICARE","19808.79","","Case rate ($19,808.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $18,507.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,649.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,318.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $18,432.04. The transfer operating threshold is the transfer adjustment factor * $18,507.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.75. The transfer capital threshold is the transfer adjustment factor * $1,376.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18718.04","18718.04","18718.04","1 through 10","17655.45","19808.79","other","Inpatient DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With McC","510","MS-DRG","","","","","","","","inpatient","","","86090.84","64568.13","MEDICARE [2001]","HB NWH MEDICARE","28773.90","","Case rate ($28,773.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,883.07, add-ons for qualifying new technology services are included. If operating cost exceeds $72,025.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,941.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $26,774.06. The transfer operating threshold is the transfer adjustment factor * $26,883.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,999.84. The transfer capital threshold is the transfer adjustment factor * $1,999.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27277.84","27277.84","27277.84","1 through 10","25646","28773.9","other","Inpatient DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/McC","512","MS-DRG","","","","","","","","inpatient","","","59279.70","44459.77","MEDICARE [2001]","HB NWH MEDICARE","15769.68","","Case rate ($15,769.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,733.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,875.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,037.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $14,673.66. The transfer operating threshold is the transfer adjustment factor * $14,733.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.02. The transfer capital threshold is the transfer adjustment factor * $1,096.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13975.33","13975.33","13975.33","1 through 10","14055.42","15899.5342","other","Inpatient DRG"
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MINOR","315","DRG","","","","","","","","inpatient","","","38642.63","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16307.799","","Fee schedule rate ($16,307.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16307.799","16307.80","16307.80","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MINOR","315","DRG","","","","","","","","inpatient","","","38642.63","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17472.5022","","Fee schedule rate ($16,307.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17472.5022","16307.80","16307.80","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","60369.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39606.34","","Standard inlier is a Case rate ($39,606.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $49,472, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,621.95) for the length of stay and the standard reimbursement.","39606.33","39606.33","39606.33","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","60369.97","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16307.799","","Fee schedule rate ($27,243.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16307.799","27243.50","27243.50","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","60369.97","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17472.5022","","Fee schedule rate ($27,243.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17472.5022","27243.50","27243.50","1 through 10","7010.54","84695.31","case rate",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","AETNA [1001]","HB CH AETNA HMO / PPO","432.31","58.3","","2190.90","412.50","9264.59","16","329.61","577.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","430.09","58","","1903.20","1903.20","3826.66","1 through 10","329.61","577.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","463.46","62.5","","2186.25","2186.25","2186.25","32","329.61","577.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","541.32","73","","5556.60","5556.60","5556.60","1 through 10","329.61","577.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","WELLPOINT [1015]","HB CH WELLPOINT","577.73","77.91","","1955.15","885.83","3150.40","26","329.61","577.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","741.53","556.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","439.73","59.3","","831.03","253.22","2394.88","18","370.77","581.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","741.53","556.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","581.73","78.45","","2481.69","1563.74","8149.28","1 through 10","370.77","581.73","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","AETNA [1001]","HB CH AETNA HMO / PPO","2391.55","58.3","","2190.90","412.50","9264.59","16","1823.4","3195.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2379.24","58","","1903.20","1903.20","3826.66","1 through 10","1823.4","3195.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2563.84","62.5","","2186.25","2186.25","2186.25","32","1823.4","3195.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2994.56","73","","5556.60","5556.60","5556.60","1 through 10","1823.4","3195.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","WELLPOINT [1015]","HB CH WELLPOINT","3195.98","77.91","","1955.15","885.83","3150.40","26","1823.4","3195.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4102.14","3076.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","2432.57","59.3","","831.03","253.22","2394.88","18","2051.07","3218.13","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4102.14","3076.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3218.13","78.45","","2481.69","1563.74","8149.28","1 through 10","2051.07","3218.13","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","AETNA [1001]","HB CH AETNA HMO / PPO","2629.14","58.3","","2190.90","412.50","9264.59","16","2004.55","3513.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2615.61","58","","1903.20","1903.20","3826.66","1 through 10","2004.55","3513.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2818.55","62.5","","2186.25","2186.25","2186.25","32","2004.55","3513.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3292.07","73","","5556.60","5556.60","5556.60","1 through 10","2004.55","3513.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","WELLPOINT [1015]","HB CH WELLPOINT","3513.49","77.91","","1955.15","885.83","3150.40","26","2004.55","3513.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4509.68","3382.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","2674.24","59.3","","831.03","253.22","2394.88","18","2254.84","3537.84","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4509.68","3382.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3537.84","78.45","","2481.69","1563.74","8149.28","1 through 10","2254.84","3537.84","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","AETNA [1001]","HB CH AETNA HMO / PPO","2009.60","58.3","","2190.90","412.50","9264.59","16","1532.19","2685.56","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1999.26","58","","1903.20","1903.20","3826.66","1 through 10","1532.19","2685.56","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2154.38","62.5","","2186.25","2186.25","2186.25","32","1532.19","2685.56","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2516.31","73","","5556.60","5556.60","5556.60","1 through 10","1532.19","2685.56","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.00","2585.25","WELLPOINT [1015]","HB CH WELLPOINT","2685.56","77.91","","1955.15","885.83","3150.40","26","1532.19","2685.56","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2044.07","59.3","","831.03","253.22","2394.88","18","1723.5","2704.17","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3447.00","2585.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2704.17","78.45","","2481.69","1563.74","8149.28","1 through 10","1723.5","2704.17","percent of total billed charges",""
"Sialot Submndblr Sublngl/Prtd Uncomp Intraoral","PX-75000056","CDM","42330","CPT","0761","RC","","","","both","","","4094.00","3070.50","AETNA [1001]","HB CH AETNA HMO / PPO","2386.80","58.3","","3646.94","3646.94","3646.94","1 through 10","176.5","3773.93","percent of total billed charges",""
"Sickle Cell Anemia Crisis,MINOR","662","DRG","","","","","","","","inpatient","","","12623.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12816.76","","Standard inlier is a Case rate ($12,816.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,887, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,819.28) for the length of stay and the standard reimbursement.","1819.28","1819.28","12234.17","1 through 10","1696","46853.45","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","22690.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17575.31","","Standard inlier is a Case rate ($17,575.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,432, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,494.74) for the length of stay and the standard reimbursement.","17575.31","17575.31","17575.31","1 through 10","1696","46853.45","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","22690.81","","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH MEDICAID","10341.84","","Case rate ($11,141.70). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,571.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2263.04","2263.04","2263.04","1 through 10","1696","46853.45","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","22690.81","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","10341.84","","Case rate ($11,141.70). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $53,571.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11170.35","11170.35","11170.35","1 through 10","1696","46853.45","case rate",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","24.95","24.95","24.95","1 through 10","5.4","42.75","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","45.00","33.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.69","59.3","","25.78","25.78","25.78","1 through 10","5.69","35.3","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","33.83","33.83","33.83","1 through 10","5.69","35.3","percent of total billed charges",""
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","both","","","2620.00","1965.00","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","outpatient","","","2620.00","1965.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","2420.08","2420.08","1 through 10","979.79","2055.39","other","Multiple Surgery"
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","both","","","1552.00","1164.00","AETNA [1001]","HB CH AETNA HMO / PPO","904.82","58.3","","855.60","855.60","855.60","1 through 10","744.89","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","both","","","1552.00","1164.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1929.27","1929.27","1929.27","1 through 10","744.89","1459.48","other","Multiple Surgery"
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","outpatient","","","1552.00","1164.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1750.49","1750.49","1 through 10","689.86","1217.54","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","AETNA [1001]","HB CH AETNA HMO / PPO","898.99","58.3","","849.93","849.93","849.93","1 through 10","685.42","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","557.06","557.06","557.06","1 through 10","685.42","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1778.58","1778.58","1778.58","1 through 10","685.42","1459.48","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","1 through 10","685.42","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($256). Procedure 2, Per diem ($128). Procedures 3 - 9999, Per diem ($64).","256.00","256.00","256.00","1 through 10","685.42","1459.48","per diem",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","270.00","270.00","270.00","1 through 10","685.42","1459.48","per diem",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","1 through 10","685.42","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1204.47","1230.03","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","615.87","1231.73","13","744.89","1873.9","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","914.41","59.3","","878.41","878.41","878.41","1 through 10","744.89","1873.9","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1750.49","1750.49","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1839.88","1839.88","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Sigmoidoscopy Flx With Band Ligation(S)","PX-75000434","CDM","45350","CPT","0750","RC","","","","both","","","2682.00","2011.50","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","979.79","2089.55","other","OPPS APC"
"Sigmoidoscopy Flx With Band Ligation(S)","PX-75000434","CDM","45350","CPT","0750","RC","","","","both","","","2682.00","2011.50","WELLPOINT [1015]","HB CH WELLPOINT","2089.55","77.91","","2054.06","2054.06","2054.06","1 through 10","979.79","2089.55","percent of total billed charges",""
"Sigmoidoscopy Flx With Band Ligation(S)","PX-75000434","CDM","45350","CPT","0750","RC","","","","outpatient","","","2682.00","2011.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","1 through 10","979.79","2104.03","other","ASC "
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2532.00","1899.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2251.81","2251.81","2251.81","1 through 10","979.79","1919.74","other","Multiple Surgery"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2532.00","1899.00","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1287.95","1400.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2532.00","1899.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1586.56","793.28","1586.56","1 through 10","979.79","1986.35","other","ASC "
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2532.00","1899.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","2420.08","2420.08","1 through 10","979.79","1986.35","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","AETNA [1001]","HB CH AETNA HMO / PPO","896.65","58.3","","848.23","848.23","848.23","1 through 10","683.64","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1929.27","1170.53","1929.27","1 through 10","683.64","1459.48","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","MEDICARE [2001]","HB NWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1822.00","1877.00","1 through 10","683.64","1459.48","per diem",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","1204.47","1230.03","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","603.09","1231.73","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","912.03","59.3","","876.66","876.66","876.66","1 through 10","744.89","1873.9","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5251.47","1750.49","5251.47","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2620.00","1965.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2620.00","1965.00","MEDICARE [2001]","HB NWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1287.95","1287.95","1287.95","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2620.00","1965.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","979.79","1919.74","per diem",""
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2620.00","1965.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","810.09","810.09","810.09","1 through 10","979.79","2055.39","other","ASC "
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC","555","MS-DRG","","","","","","","","inpatient","","","40333.51","30250.13","MEDICARE [2001]","HB NWH MEDICARE","12591.74","","Case rate ($12,591.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,764.29, add-ons for qualifying new technology services are included. If operating cost exceeds $56,906.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,817.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,716.59. The transfer operating threshold is the transfer adjustment factor * $11,764.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.15. The transfer capital threshold is the transfer adjustment factor * $875.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12852.19","12852.19","12852.19","1 through 10","11222.94","13316.5274","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","23359.15","17519.36","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7912.46","","Case rate ($7,912.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,392.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,534.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,491.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,362.53. The transfer operating threshold is the transfer adjustment factor * $7,392.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.93. The transfer capital threshold is the transfer adjustment factor * $549.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7041.05","7041.05","7041.05","1 through 10","7052.33","8074.3685","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","23359.15","17519.36","MEDICARE [2001]","HB NWH MEDICARE","7912.46","","Case rate ($7,912.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,392.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,534.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,491.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,362.53. The transfer operating threshold is the transfer adjustment factor * $7,392.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.93. The transfer capital threshold is the transfer adjustment factor * $549.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7792.71","353.86","7806.83","13","7052.33","8074.3685","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","25540.21","19155.16","MEDICARE [2001]","HB NWH MEDICARE","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12275.71","6634.93","12297.78","17","1293.36","12719.2318","other","Inpatient Psych"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","25540.21","19155.16","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","42.48","42.48","42.48","1 through 10","1293.36","12719.2318","other","Inpatient Psych"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","25540.21","19155.16","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","1293.36","","Case rate ($1,293.36) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12641.26","12641.26","12641.26","1 through 10","1293.36","12719.2318","other","Inpatient Psych"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","25178.32","18883.74","MEDICARE [2001]","HB NWH MEDICARE","1258.72","","Case rate ($1,258.72) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $32,870.05 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.374, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-49: 1.01, 50-54: 1.02, 55-59: 1.04, 60-64: 1.07, 65-69: 1.1, 70-74: 1.13, 75-79: 1.15, 80-120: 1.17. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Coagulation Factor Deficits: 1.13; Tracheotomy: 1.06; Renal Failure, Acute: 1.11; Renal Failure, Chronic: 1.11; Oncology Treatment: 1.07; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.13; Eating Disorders: 1.12; Infectious Diseases: 1.07; Drug Alcohol Induced Mental Disorders: 1.03; Cardiac Conditions: 1.11; Gangrene: 1.1; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.12; Artificial Openings - Digestive and Urinary: 1.08; Musculoskeletal and Connective Tissue Diseases, Severe: 1.09; Poisoning: 1.11. Day adjustment factors: Days 1: 1.31, 2: 1.12, 3: 1.08, 4: 1.05, 5: 1.04, 6: 1.02, 7-8: 1.01, 9-10: 1, 11-14: 0.99, 15: 0.98, 16-17: 0.97, 18: 0.96, 19-21: 0.95, 22-9999: 0.92. The ED day 1 adjustment factor is 1.31, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7582.84","1750.11","7582.84","17","1258.72","8217.13","other","Inpatient Psych"
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","30931.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15463.32","","Standard inlier is a Case rate ($15,463.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,194.95) for the length of stay and the standard reimbursement.","21633.38","21633.38","21633.38","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","30931.71","","MASSHEALTH [3001]","HB NWH MEDICAID","6144.79","","Case rate ($6,620.04). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,050.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3204.73","3204.73","3204.73","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","11617.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8305.68","","Standard inlier is a Case rate ($8,305.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,179.02) for the length of stay and the standard reimbursement.","8305.68","8305.68","8305.68","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","11617.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8921.96","","Standard inlier is a Case rate ($8,921.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,266.43) for the length of stay and the standard reimbursement.","8516.41","8516.41","8516.41","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","22374.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14395.21","","Standard inlier is a Case rate ($14,395.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,043.46) for the length of stay and the standard reimbursement.","14395.20","14395.20","14395.20","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","22374.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7924.281","","Fee schedule rate ($11,727.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7924.281","11727.16","11727.16","1 through 10","4767.09","31112.24","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","22374.50","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8320.4545","","Fee schedule rate ($12,313.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8320.4545","22011.53","22011.53","1 through 10","4767.09","31112.24","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7191.74","","Case rate ($6,982.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,448.68. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7371.03","7351.23","11812.94","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","7677.18","","Case rate ($7,677.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,143.59. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7071.25","7071.25","7071.25","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6629.04","6629.04","6629.04","1 through 10","6842.62","8272.56","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","FALLON HEALTH [1008]","HB NWH MEDICARE","7677.18","","Case rate ($7,677.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,143.59. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8967.52","8967.52","8967.52","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","HUMANA [1012]","HB NWH MEDICARE","7677.18","","Case rate ($7,677.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,143.59. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6168.26","6168.26","6168.26","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","MEDICARE [2001]","HB NWH MEDICARE","7677.18","","Case rate ($7,677.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,143.59. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7826.22","1369.92","7840.29","71","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6842.62","","Case rate ($6,982.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,448.68. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7006.01","6993.61","7009.61","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","6842.62","","Case rate ($6,982.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,448.68. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7972.43","7972.43","7972.43","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","19289.95","14467.46","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6842.62","","Case rate ($6,982.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,172.68, add-ons for qualifying new technology services are included. If operating cost exceeds $52,314.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,475.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,448.68. The transfer operating threshold is the transfer adjustment factor * $7,172.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.58. The transfer capital threshold is the transfer adjustment factor * $533.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6989.61","5663.38","7019.62","1 through 10","6842.62","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","11729.51","","Case rate ($11,387.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,698.43, add-ons for qualifying new technology services are included. If operating cost exceeds $56,840.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,812.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,517.62. The transfer operating threshold is the transfer adjustment factor * $11,698.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.25. The transfer capital threshold is the transfer adjustment factor * $870.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11803.57","11793.57","11833.17","1 through 10","11160.11","13492.32","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","12521.25","","Case rate ($12,521.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,698.43, add-ons for qualifying new technology services are included. If operating cost exceeds $56,840.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,812.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,650.99. The transfer operating threshold is the transfer adjustment factor * $11,698.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.25. The transfer capital threshold is the transfer adjustment factor * $870.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11363.13","11363.13","11464.67","11","11160.11","13492.32","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10289.05","10289.05","13928.08","1 through 10","11160.11","13492.32","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","MEDICARE [2001]","HB NWH MEDICARE","12521.25","","Case rate ($12,521.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,698.43, add-ons for qualifying new technology services are included. If operating cost exceeds $56,840.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,812.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,650.99. The transfer operating threshold is the transfer adjustment factor * $11,698.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.25. The transfer capital threshold is the transfer adjustment factor * $870.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12576.35","6299.48","12598.95","140","11160.11","13492.32","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","11160.11","","Case rate ($11,387.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,698.43, add-ons for qualifying new technology services are included. If operating cost exceeds $56,840.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,812.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,517.62. The transfer operating threshold is the transfer adjustment factor * $11,698.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.25. The transfer capital threshold is the transfer adjustment factor * $870.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11235.98","11231.98","11269.97","1 through 10","11160.11","13492.32","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","24454.12","18340.59","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","11160.11","","Case rate ($11,387.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,698.43, add-ons for qualifying new technology services are included. If operating cost exceeds $56,840.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,812.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,517.62. The transfer operating threshold is the transfer adjustment factor * $11,698.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.25. The transfer capital threshold is the transfer adjustment factor * $870.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11235.38","11231.98","11264.08","11","11160.11","13492.32","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12931.45","9698.59","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","5608.64","","Case rate ($5,445.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,593.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,358.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,029.16. The transfer operating threshold is the transfer adjustment factor * $5,593.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.12. The transfer capital threshold is the transfer adjustment factor * $416.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5580.15","5580.15","5580.15","1 through 10","5336.37","6451.55","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12931.45","9698.59","MEDICARE [2001]","HB NWH MEDICARE","5445.28","","Case rate ($5,445.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,593.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,358.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,029.16. The transfer operating threshold is the transfer adjustment factor * $5,593.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.12. The transfer capital threshold is the transfer adjustment factor * $416.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5943.15","1033.09","5953.83","1 through 10","5336.37","6451.55","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12931.45","9698.59","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","5336.37","","Case rate ($5,445.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,593.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,358.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,029.16. The transfer operating threshold is the transfer adjustment factor * $5,593.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.12. The transfer capital threshold is the transfer adjustment factor * $416.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4649.23","4649.23","4649.23","1 through 10","5336.37","6451.55","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12931.45","9698.59","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","5336.37","","Case rate ($5,445.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,593.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,358.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,029.16. The transfer operating threshold is the transfer adjustment factor * $5,593.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.12. The transfer capital threshold is the transfer adjustment factor * $416.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6016.18","6016.18","6016.18","1 through 10","5336.37","6451.55","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12931.45","9698.59","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","5336.37","","Case rate ($5,445.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $5,593.78, add-ons for qualifying new technology services are included. If operating cost exceeds $50,736.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,358.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,029.16. The transfer operating threshold is the transfer adjustment factor * $5,593.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $416.12. The transfer capital threshold is the transfer adjustment factor * $416.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5307.85","5307.85","5342.05","1 through 10","5336.37","6451.55","other","Inpatient DRG"
"Sincalide Injection","PX-63601059","CDM","J2805","HCPCS","0636","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","107.16","107.16","107.16","1 through 10","95.93","328.23","percent of total billed charges",""
"Sincalide Injection","PX-63601059","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","181.00","135.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.48","52.2","","105.02","105.02","105.02","1 through 10","90.5","292.34","percent of total billed charges",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","75989.44","56992.08","MEDICARE [2001]","HB NWH MEDICARE","38300.10","","Case rate ($38,300.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $35,783.27, add-ons for qualifying new technology services are included. If operating cost exceeds $80,925.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,603.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,638.17. The transfer operating threshold is the transfer adjustment factor * $35,783.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,661.93. The transfer capital threshold is the transfer adjustment factor * $2,661.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37338.69","37338.69","37405.83","12","34136.65","38687.7458","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","75989.44","56992.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","34136.65","","Case rate ($34,833.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $35,783.27, add-ons for qualifying new technology services are included. If operating cost exceeds $80,925.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,603.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $32,171.39. The transfer operating threshold is the transfer adjustment factor * $35,783.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,661.93. The transfer capital threshold is the transfer adjustment factor * $2,661.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33371.41","33371.41","33371.41","1 through 10","34136.65","38687.7458","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","75989.44","56992.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","34136.65","","Case rate ($34,833.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $35,783.27, add-ons for qualifying new technology services are included. If operating cost exceeds $80,925.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,603.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $32,171.39. The transfer operating threshold is the transfer adjustment factor * $35,783.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,661.93. The transfer capital threshold is the transfer adjustment factor * $2,661.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33354.30","33354.30","33354.30","1 through 10","34136.65","38687.7458","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","68277.38","51208.03","MEDICARE [2001]","HB NWH MEDICARE","46175.26","","Case rate ($46,175.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $47,434.53, add-ons for qualifying new technology services are included. If operating cost exceeds $92,576.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,470.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,646.59. The transfer operating threshold is the transfer adjustment factor * $47,434.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,528.67. The transfer capital threshold is the transfer adjustment factor * $3,528.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49153.44","49153.44","49153.44","1 through 10","30517.454","47560.52","other","Inpatient Replacement Plans DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","68277.38","51208.03","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","45251.75","","Case rate ($46,175.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $47,434.53, add-ons for qualifying new technology services are included. If operating cost exceeds $92,576.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,470.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $42,646.59. The transfer operating threshold is the transfer adjustment factor * $47,434.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,528.67. The transfer capital threshold is the transfer adjustment factor * $3,528.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","43912.39","43912.39","43912.39","1 through 10","30517.454","47560.52","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","65167.70","48875.77","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","30773.45","","Case rate ($30,773.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,751.22, add-ons for qualifying new technology services are included. If operating cost exceeds $73,893.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,080.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $28,634.64. The transfer operating threshold is the transfer adjustment factor * $28,751.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,138.81. The transfer capital threshold is the transfer adjustment factor * $2,138.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26612.00","26612.00","26612.00","1 through 10","27428.19","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","65167.70","48875.77","MEDICARE [2001]","HB NWH MEDICARE","30773.45","","Case rate ($30,773.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,751.22, add-ons for qualifying new technology services are included. If operating cost exceeds $73,893.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,080.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $28,634.64. The transfer operating threshold is the transfer adjustment factor * $28,751.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,138.81. The transfer capital threshold is the transfer adjustment factor * $2,138.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29506.25","29452.92","29506.25","15","27428.19","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","65167.70","48875.77","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","27428.19","","Case rate ($27,987.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,751.22, add-ons for qualifying new technology services are included. If operating cost exceeds $73,893.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,080.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,849.14. The transfer operating threshold is the transfer adjustment factor * $28,751.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,138.81. The transfer capital threshold is the transfer adjustment factor * $2,138.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26312.83","26312.83","26312.83","1 through 10","27428.19","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","65167.70","48875.77","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","27428.19","","Case rate ($27,987.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,751.22, add-ons for qualifying new technology services are included. If operating cost exceeds $73,893.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,080.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $25,849.14. The transfer operating threshold is the transfer adjustment factor * $28,751.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,138.81. The transfer capital threshold is the transfer adjustment factor * $2,138.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26319.45","26319.45","26319.45","1 through 10","27428.19","33160.06","other","Inpatient DRG"
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB CH AETNA HMO / PPO","138.17","58.3","","464.71","67.87","1012.10","221","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.17","58.3","","293.04","293.04","293.04","11","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.61","53","","983.89","983.89","983.89","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","137.46","58","","677.18","677.18","677.18","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.13","62.5","","46.58","46.58","46.58","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","747.15","747.15","747.15","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","1141.67","481.21","1141.67","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","76.54","76.54","76.54","1 through 10","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","WELLPOINT [1015]","HB CH WELLPOINT","184.65","77.91","","273.64","94.28","1367.51","138","105.35","184.65","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.54","59.3","","720.78","230.14","2010.94","427","118.5","185.93","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","140.54","59.3","","344.45","344.45","344.45","1 through 10","118.5","185.93","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","1120.13","1120.13","1120.13","1 through 10","118.5","185.93","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","456.17","105.33","1284.66","242","118.5","185.93","percent of total billed charges",""
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","49067.04","36800.28","MEDICARE [2001]","HB NWH MEDICARE","14637.70","","Case rate ($14,637.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,036.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,179.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,060.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $13,519.10. The transfer operating threshold is the transfer adjustment factor * $15,036.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,118.60. The transfer capital threshold is the transfer adjustment factor * $1,118.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15979.81","15979.81","15979.81","1 through 10","14344.95","17342.72","other","Inpatient Replacement Plans DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","97101.51","72826.13","MEDICARE [2001]","HB NWH MEDICARE","28017.52","","Case rate ($28,017.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,176.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,318.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,889.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $26,070.25. The transfer operating threshold is the transfer adjustment factor * $26,176.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,947.27. The transfer capital threshold is the transfer adjustment factor * $1,947.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28781.51","28781.51","28781.51","1 through 10","24971.85","29767.8678","other","Inpatient DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","97101.51","72826.13","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","24971.85","","Case rate ($25,481.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,176.39, add-ons for qualifying new technology services are included. If operating cost exceeds $71,318.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,889.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $23,534.21. The transfer operating threshold is the transfer adjustment factor * $26,176.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,947.27. The transfer capital threshold is the transfer adjustment factor * $1,947.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19487.80","19487.80","19487.80","1 through 10","24971.85","29767.8678","other","Inpatient DRG"
"Skin Debridement Without Cc/McC","572","MS-DRG","","","","","","","","inpatient","","","49030.00","36772.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","9732.83","","Case rate ($9,931.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,202.31, add-ons for qualifying new technology services are included. If operating cost exceeds $55,344.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,700.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,172.51. The transfer operating threshold is the transfer adjustment factor * $10,202.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $758.95. The transfer capital threshold is the transfer adjustment factor * $758.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9777.25","9777.25","9777.25","1 through 10","9732.83","11297.1936","other","Inpatient DRG"
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,EXTREME","361","DRG","","","","","","","","inpatient","","","56071.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","134888.01","","Standard inlier is a Case rate ($134,888.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $140,469, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,146.78) for the length of stay and the standard reimbursement.","134888.01","134888.01","134888.01","1 through 10","21147.48","329307.97","case rate",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","69633.19","52224.89","MEDICARE [2001]","HB NWH MEDICARE","15542.22","","Case rate ($15,542.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,966.08, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,129.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,354.50. The transfer operating threshold is the transfer adjustment factor * $15,966.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.72. The transfer capital threshold is the transfer adjustment factor * $1,187.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18288.90","18288.90","18288.90","1 through 10","15231.38","18414.38","other","Inpatient Replacement Plans DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC","622","MS-DRG","","","","","","","","inpatient","","","85471.62","64103.71","MEDICARE [2001]","HB NWH MEDICARE","33905.67","","Case rate ($33,905.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $31,677.61, add-ons for qualifying new technology services are included. If operating cost exceeds $76,819.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,298.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $31,549.16. The transfer operating threshold is the transfer adjustment factor * $31,677.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,356.50. The transfer capital threshold is the transfer adjustment factor * $2,356.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35714.30","35714.30","35714.30","1 through 10","30219.92","36535.19","other","Inpatient DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","24044.77","18033.58","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","11300.94","","Case rate ($11,300.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,558.31, add-ons for qualifying new technology services are included. If operating cost exceeds $55,700.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,727.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,515.50. The transfer operating threshold is the transfer adjustment factor * $10,558.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.44. The transfer capital threshold is the transfer adjustment factor * $785.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10543.76","10543.76","10543.76","1 through 10","10072.46","12177.37","other","Inpatient DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","24044.77","18033.58","MEDICARE [2001]","HB NWH MEDICARE","11300.94","","Case rate ($11,300.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $10,558.31, add-ons for qualifying new technology services are included. If operating cost exceeds $55,700.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,727.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,515.50. The transfer operating threshold is the transfer adjustment factor * $10,558.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.44. The transfer capital threshold is the transfer adjustment factor * $785.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11669.65","11669.50","11690.64","1 through 10","10072.46","12177.37","other","Inpatient DRG"
"Skin Ulcers With McC","592","MS-DRG","","","","","","","","inpatient","","","34588.79","25941.59","MEDICARE [2001]","HB NWH MEDICARE","16767.29","","Case rate ($16,767.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,224.56, add-ons for qualifying new technology services are included. If operating cost exceeds $62,366.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,223.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $15,485.96. The transfer operating threshold is the transfer adjustment factor * $17,224.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,281.34. The transfer capital threshold is the transfer adjustment factor * $1,281.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19660.98","19660.98","19660.98","1 through 10","16431.94","19865.85","other","Inpatient Replacement Plans DRG"
"Skin Ulcers,MAJOR","380","DRG","","","","","","","","inpatient","","","11185.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12864.4986","","Fee schedule rate ($25,469.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12864.4986","25469.08","25469.08","1 through 10","6699.98","42023.61","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","16598.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17596.38","","Standard inlier is a Case rate ($17,596.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $28,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,497.73) for the length of stay and the standard reimbursement.","16798.64","16798.64","16798.64","1 through 10","6699.98","42023.61","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","16598.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12864.4986","","Fee schedule rate ($16,741.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12864.4986","25469.08","25469.08","1 through 10","6699.98","42023.61","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","16598.01","","MASSHEALTH [3001]","HB NWH MEDICAID","6699.98","","Case rate ($7,218.17). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,648.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7513.57","7513.57","7513.57","1 through 10","6699.98","42023.61","case rate",""
"Skin/Muc Mem/Subq Tissue Unlstd","PX-76001780","CDM","17999","CPT","0761","RC","","","","outpatient","","","1456.00","1092.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","729.46","50.1","","142.89","142.89","142.89","1 through 10","567.68","1142.23","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","AETNA [1001]","HB CH AETNA HMO / PPO","1504.14","58.3","","464.71","67.87","1012.10","221","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1504.14","58.3","","293.04","293.04","293.04","11","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1367.40","53","","983.89","983.89","983.89","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1496.40","58","","677.18","677.18","677.18","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1612.50","62.5","","46.58","46.58","46.58","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1883.40","73","","747.15","747.15","747.15","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.81","44.45","","1141.67","481.21","1141.67","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.81","44.45","","76.54","76.54","76.54","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","WELLPOINT [1015]","HB CH WELLPOINT","2010.08","77.91","","273.64","94.28","1367.51","138","1146.81","2010.08","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1529.94","59.3","","720.78","230.14","2010.94","427","1290","2024.01","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1529.94","59.3","","344.45","344.45","344.45","1 through 10","1290","2024.01","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1290","2024.01","percent of total billed charges",""
"SLED OLECRANON 47MM BAND TENSION FIXATION","SUP-ITM-10082959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","456.17","105.33","1284.66","242","1290","2024.01","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1530.90","1160.93","1884.08","89","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","5253.92","5253.92","5253.92","1 through 10","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","12181.47","12181.47","12181.47","1 through 10","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","1350.68","1350.68","1350.68","1 through 10","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1910.74","891.94","1910.74","1 through 10","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","1829.79","1561.50","2617.12","88","33.34","58.43","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1359.46","1201.30","1689.00","61","37.5","58.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","1718.92","1718.92","1718.92","1 through 10","37.5","58.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1910.74","1019.06","2344.84","74","37.5","58.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1530.90","1160.93","1884.08","89","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","5253.92","5253.92","5253.92","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","12181.47","12181.47","12181.47","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1910.74","891.94","1910.74","1 through 10","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","1829.79","1561.50","2617.12","88","1066.8","1869.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1359.46","1201.30","1689.00","61","1200","1882.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1718.92","1718.92","1718.92","1 through 10","1200","1882.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 20F 18ID XXL S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10002426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1910.74","1019.06","2344.84","74","1200","1882.8","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","both","","","3652.50","2739.37","AETNA [1001]","HB CH AETNA HMO / PPO","2129.41","58.3","","1952.48","1215.31","1952.48","1 through 10","1623.54","2845.66","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","both","","","3652.50","2739.37","WELLPOINT [1015]","HB CH WELLPOINT","2845.66","77.91","","2735.63","2146.75","4736.42","1 through 10","1623.54","2845.66","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3652.50","2739.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2165.93","59.3","","1597.25","1552.67","1756.87","1 through 10","1826.25","2865.39","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3652.50","2739.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2865.39","78.45","","2647.39","1568.87","3176.87","1 through 10","1826.25","2865.39","percent of total billed charges",""
"SLING INCONTINENCE SOLYX SIS URETHRAL MESH","SUP-ITM-10304227","CDM","C1771","HCPCS","0278","RC","","","","both","","","4043.51","3032.63","AETNA [1001]","HB CH AETNA HMO / PPO","2357.37","58.3","","1952.48","1215.31","1952.48","1 through 10","1797.34","3150.3","percent of total billed charges",""
"SLING INCONTINENCE SOLYX SIS URETHRAL MESH","SUP-ITM-10304227","CDM","C1771","HCPCS","0278","RC","","","","both","","","4043.51","3032.63","WELLPOINT [1015]","HB CH WELLPOINT","3150.30","77.91","","2735.63","2146.75","4736.42","1 through 10","1797.34","3150.3","percent of total billed charges",""
"SLING INCONTINENCE SOLYX SIS URETHRAL MESH","SUP-ITM-10304227","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4043.51","3032.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","2397.80","59.3","","1597.25","1552.67","1756.87","1 through 10","2021.76","3172.13","percent of total billed charges",""
"SLING INCONTINENCE SOLYX SIS URETHRAL MESH","SUP-ITM-10304227","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4043.51","3032.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3172.13","78.45","","2647.39","1568.87","3176.87","1 through 10","2021.76","3172.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","3443.53","2582.65","AETNA [1001]","HB CH AETNA HMO / PPO","2007.58","58.3","","1952.48","1215.31","1952.48","1 through 10","1530.65","2682.85","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","3443.53","2582.65","WELLPOINT [1015]","HB CH WELLPOINT","2682.85","77.91","","2735.63","2146.75","4736.42","1 through 10","1530.65","2682.85","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3443.53","2582.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","2042.01","59.3","","1597.25","1552.67","1756.87","1 through 10","1721.77","2701.45","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3443.53","2582.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2701.45","78.45","","2647.39","1568.87","3176.87","1 through 10","1721.77","2701.45","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","372.4","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","41.98","372.4","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","500.24","1 through 10","44.17","307.52","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","167.00","125.25","AETNA [1001]","HB CH AETNA HMO / PPO","97.36","58.3","","121.91","121.91","121.91","1 through 10","18.27","158.65","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","167.00","125.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.03","59.3","","125.99","125.99","125.99","1 through 10","14.12","131.01","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","167.00","125.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.01","78.45","","165.29","97.95","215.00","1 through 10","14.12","131.01","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Potassium, Feces 84999","PX-30003318","CDM","84999","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","38.44","38.44","38.44","1 through 10","4.28","46.29","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Strep Pneumoniae Ag 87899","PX-30003322","CDM","87899","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","216.59","216.59","216.59","1 through 10","15.75","131.1","percent of total billed charges",""
"Slm Tegretol Epoxide 2 80299","PX-30003296","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Slm Tegretol Epoxide 2 80299","PX-30003296","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Slm Tegretol Epoxide 2 80299","PX-30003296","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Slm Voriconazole, Serum 80299","PX-30003298","CDM","80299","CPT","0300","RC","","","","both","","","196.00","147.00","AETNA [1001]","HB CH AETNA HMO / PPO","114.27","58.3","","121.91","121.91","121.91","1 through 10","18.27","186.2","percent of total billed charges",""
"Slm Voriconazole, Serum 80299","PX-30003298","CDM","80299","CPT","0300","RC","","","","outpatient","","","196.00","147.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.23","59.3","","125.99","125.99","125.99","1 through 10","14.12","153.76","percent of total billed charges",""
"Slm Voriconazole, Serum 80299","PX-30003298","CDM","80299","CPT","0300","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","153.76","78.45","","165.29","97.95","215.00","1 through 10","14.12","153.76","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","AETNA [1001]","HB CH AETNA HMO / PPO","23.90","58.3","","22.68","22.68","22.68","173","4.18","38.95","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","TRICARE [160005]","HB NWH TRICARE","38.95","95","","5.15","4.89","5.15","1 through 10","4.18","38.95","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.22","44.45","","30.75","18.22","30.75","1 through 10","4.18","38.95","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.22","44.45","","18.22","18.22","18.22","1 through 10","4.18","38.95","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","41.00","30.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.31","59.3","","23.44","23.44","70.32","142","4.4","32.16","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.16","78.45","","30.75","18.22","30.75","157","4.4","32.16","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","111.14","35","8.72","95.95","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB NWH TRICARE","95.95","95","","10.72","10.72","10.72","1 through 10","8.72","95.95","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","48","9.17","79.23","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","44.65","75.34","30","9.17","79.23","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","24.95","24.95","24.95","1 through 10","4.71","42.75","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","45.00","33.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.69","59.3","","25.78","25.78","25.78","1 through 10","4.97","35.3","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","45.00","33.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","33.83","33.83","33.83","1 through 10","4.97","35.3","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","33.83","20.05","33.83","1 through 10","4.97","35.3","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","24.95","7.08","24.95","1 through 10","4.96","42.75","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","45.00","33.75","CHAMPVA [160001]","HB NWH TRICARE","42.75","95","","6.10","6.10","6.10","1 through 10","4.96","42.75","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.00","44.45","","35.64","33.83","35.64","1 through 10","4.96","42.75","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","45.00","33.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.69","59.3","","25.78","25.78","94.38","1 through 10","5.03","35.3","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","33.83","20.05","88.00","1 through 10","5.03","35.3","percent of total billed charges",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","38642.63","28981.97","MEDICARE [2001]","HB NWH MEDICARE","15145.41","","Case rate ($15,145.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $15,558.45, add-ons for qualifying new technology services are included. If operating cost exceeds $60,700.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,099.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,988.01. The transfer operating threshold is the transfer adjustment factor * $15,558.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,157.40. The transfer capital threshold is the transfer adjustment factor * $1,157.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16855.93","16855.93","17064.09","1 through 10","14842.5","17648.8983","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","53399.76","40049.82","MEDICARE [2001]","HB NWH MEDICARE","30148.53","","Case rate ($30,148.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $28,167.36, add-ons for qualifying new technology services are included. If operating cost exceeds $73,309.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,037.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,053.15. The transfer operating threshold is the transfer adjustment factor * $28,167.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,095.38. The transfer capital threshold is the transfer adjustment factor * $2,095.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27106.71","23122.66","29048.03","1 through 10","26871.21","31335.2743","other","Inpatient DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","53111.81","39833.86","MEDICARE [2001]","HB NWH MEDICARE","11660.79","","Case rate ($11,660.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,978.79, add-ons for qualifying new technology services are included. If operating cost exceeds $57,121.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,833.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,769.67. The transfer operating threshold is the transfer adjustment factor * $11,978.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.10. The transfer capital threshold is the transfer adjustment factor * $891.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12465.67","12465.67","12465.67","1 through 10","11427.57","13815.66","other","Inpatient Replacement Plans DRG"
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1530.90","1160.93","1884.08","89","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","5253.92","5253.92","5253.92","1 through 10","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2125.70","58","","12181.47","12181.47","12181.47","1 through 10","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2290.63","62.5","","1350.68","1350.68","1350.68","1 through 10","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.09","44.45","","1910.74","891.94","1910.74","1 through 10","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","1829.79","1561.50","2617.12","88","1629.09","2855.4","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1359.46","1201.30","1689.00","61","1832.5","2875.19","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1832.5","2875.19","percent of total billed charges",""
"SOLUTION COMPONENT FEMORAL KNEE NEXGEN CR FLEX POROUS CRUCIATE RETAINING LT SIZE G MINUS","SUP-ITM-10077615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","1910.74","1019.06","2344.84","74","1832.5","2875.19","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","AETNA [1001]","HB CH AETNA HMO / PPO","3817.37","58.3","","1530.90","1160.93","1884.08","89","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3470.33","53","","5253.92","5253.92","5253.92","1 through 10","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3797.72","58","","12181.47","12181.47","12181.47","1 through 10","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4092.38","62.5","","1350.68","1350.68","1350.68","1 through 10","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2910.50","44.45","","1910.74","891.94","1910.74","1 through 10","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","WELLPOINT [1015]","HB CH WELLPOINT","5101.39","77.91","","1829.79","1561.50","2617.12","88","2910.5","5101.39","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1359.46","1201.30","1689.00","61","3273.9","5136.75","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1718.92","1718.92","1718.92","1 through 10","3273.9","5136.75","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5136.75","78.45","","1910.74","1019.06","2344.84","74","3273.9","5136.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","197.00","147.75","AETNA [1001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","108.86","19","20.83","187.15","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","197.00","147.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","108.86","108.86","108.86","1 through 10","20.83","187.15","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","197.00","147.75","TRICARE [160005]","HB NWH TRICARE","187.15","95","","25.62","25.62","25.62","1 through 10","20.83","187.15","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","112.51","337.53","15","17.43","154.55","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","87.48","147.61","21","17.43","154.55","percent of total billed charges",""
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","both","","","150.00","112.50","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","79.5","379.37","other","OPPS APC"
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","both","","","150.00","112.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","313.68","104.56","313.68","1 through 10","79.5","379.37","other","OPPS APC"
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.67","102.47","102.67","1 through 10","79.5","379.37","other","OPPS APC"
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","outpatient","","","150.00","112.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","73.61","49.07","","3641.00","3641.00","3641.00","1 through 10","66.68","434.39","percent of total billed charges",""
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","outpatient","","","150.00","112.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","75.15","50.1","","188.55","188.55","188.55","1 through 10","66.68","434.39","percent of total billed charges",""
"Sp Cardiac Calcium Scoring Screen","PX-35000098","CDM","76497","CPT","0999","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","1268.16","1268.16","1268.16","1 through 10","66.68","434.39","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","AETNA [1001]","HB CH AETNA HMO / PPO","93.28","58.3","","51.36","0.57","85.05","29","50.28","171.92","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.12","44.45","","68.34","68.34","68.34","1 through 10","50.28","171.92","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.88","59.3","","87.90","87.90","131.89","19","58.56","125.52","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","125.52","78.45","","115.32","115.32","115.32","16","58.56","125.52","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","51.36","0.57","85.05","29","49.78","171.92","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","68.34","68.34","68.34","1 through 10","49.78","171.92","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","87.90","87.90","131.89","19","40.99","87.86","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","115.32","115.32","115.32","16","40.99","87.86","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","AETNA [1001]","HB CH AETNA HMO / PPO","951.46","58.3","","464.71","67.87","1012.10","221","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","951.46","58.3","","293.04","293.04","293.04","11","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.96","53","","983.89","983.89","983.89","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","946.56","58","","677.18","677.18","677.18","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1020.00","62.5","","46.58","46.58","46.58","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1191.36","73","","747.15","747.15","747.15","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.42","44.45","","1141.67","481.21","1141.67","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.42","44.45","","76.54","76.54","76.54","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","WELLPOINT [1015]","HB CH WELLPOINT","1271.49","77.91","","273.64","94.28","1367.51","138","725.42","1271.49","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.78","59.3","","720.78","230.14","2010.94","427","816","1280.3","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","967.78","59.3","","344.45","344.45","344.45","1 through 10","816","1280.3","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1280.30","78.45","","1120.13","1120.13","1120.13","1 through 10","816","1280.3","percent of total billed charges",""
"SPACER ALTIVATE 8MM REVERSE SM WITH SCREW","SUP-ITM-10268466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.30","78.45","","456.17","105.33","1284.66","242","816","1280.3","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","2190.90","412.50","9264.59","16","1666.88","2921.63","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","1903.20","1903.20","3826.66","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","2186.25","2186.25","2186.25","32","1666.88","2921.63","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","5556.60","5556.60","5556.60","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1955.15","885.83","3150.40","26","1666.88","2921.63","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","831.03","253.22","2394.88","18","1875","2941.88","percent of total billed charges",""
"SPACER CERVICAL 5MM ZERO P PEEK OPTIMA LORDOTIC VARIABLE ANGLE PREASSEMBLED","SUP-ITM-10178676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2481.69","1563.74","8149.28","1 through 10","1875","2941.88","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","AETNA [1001]","HB CH AETNA HMO / PPO","951.46","58.3","","1530.90","1160.93","1884.08","89","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.96","53","","5253.92","5253.92","5253.92","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","946.56","58","","12181.47","12181.47","12181.47","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1020.00","62.5","","1350.68","1350.68","1350.68","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.42","44.45","","1910.74","891.94","1910.74","1 through 10","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","WELLPOINT [1015]","HB CH WELLPOINT","1271.49","77.91","","1829.79","1561.50","2617.12","88","725.42","1271.49","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.78","59.3","","1359.46","1201.30","1689.00","61","816","1280.3","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","967.78","59.3","","1718.92","1718.92","1718.92","1 through 10","816","1280.3","percent of total billed charges",""
"SPACER SHOULDER XLONG RSP RETAINING SCREW","SUP-ITM-10208161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.30","78.45","","1910.74","1019.06","2344.84","74","816","1280.3","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","AETNA [1001]","HB CH AETNA HMO / PPO","5013.80","58.3","","2190.90","412.50","9264.59","16","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4988.00","58","","1903.20","1903.20","3826.66","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5375.00","62.5","","2186.25","2186.25","2186.25","32","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6278.00","73","","5556.60","5556.60","5556.60","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","WELLPOINT [1015]","HB CH WELLPOINT","6700.26","77.91","","1955.15","885.83","3150.40","26","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5099.80","59.3","","831.03","253.22","2394.88","18","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6746.70","78.45","","2481.69","1563.74","8149.28","1 through 10","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","AETNA [1001]","HB CH AETNA HMO / PPO","5013.80","58.3","","2190.90","412.50","9264.59","16","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4988.00","58","","1903.20","1903.20","3826.66","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5375.00","62.5","","2186.25","2186.25","2186.25","32","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6278.00","73","","5556.60","5556.60","5556.60","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","WELLPOINT [1015]","HB CH WELLPOINT","6700.26","77.91","","1955.15","885.83","3150.40","26","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5099.80","59.3","","831.03","253.22","2394.88","18","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 12X7.9MM 3.3CC MED 10DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6746.70","78.45","","2481.69","1563.74","8149.28","1 through 10","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","AETNA [1001]","HB CH AETNA HMO / PPO","5013.80","58.3","","2190.90","412.50","9264.59","16","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4988.00","58","","1903.20","1903.20","3826.66","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5375.00","62.5","","2186.25","2186.25","2186.25","32","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6278.00","73","","5556.60","5556.60","5556.60","1 through 10","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","WELLPOINT [1015]","HB CH WELLPOINT","6700.26","77.91","","1955.15","885.83","3150.40","26","3822.7","6700.26","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5099.80","59.3","","831.03","253.22","2394.88","18","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 15X9.7MM 2.5CC SM 14DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6746.70","78.45","","2481.69","1563.74","8149.28","1 through 10","4300","6746.7","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","2190.90","412.50","9264.59","16","1666.88","2921.63","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","1903.20","1903.20","3826.66","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","2186.25","2186.25","2186.25","32","1666.88","2921.63","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","5556.60","5556.60","5556.60","1 through 10","1666.88","2921.63","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1955.15","885.83","3150.40","26","1666.88","2921.63","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","831.03","253.22","2394.88","18","1875","2941.88","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2481.69","1563.74","8149.28","1 through 10","1875","2941.88","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","2190.90","412.50","9264.59","16","1133.48","1986.71","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1479.00","58","","1903.20","1903.20","3826.66","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1593.75","62.5","","2186.25","2186.25","2186.25","32","1133.48","1986.71","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","5556.60","5556.60","5556.60","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","1955.15","885.83","3150.40","26","1133.48","1986.71","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","831.03","253.22","2394.88","18","1275","2000.48","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","2481.69","1563.74","8149.28","1 through 10","1275","2000.48","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","58.00","43.50","AETNA [1001]","HB CH AETNA HMO / PPO","33.81","58.3","","31.75","31.75","31.75","1 through 10","5.87","55.1","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","58.00","43.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.39","59.3","","32.82","32.79","98.46","1 through 10","6.19","47.09","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.50","78.45","","43.05","25.51","43.05","1 through 10","6.19","47.09","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","351.00","263.25","AETNA [1001]","HB CH AETNA HMO / PPO","204.63","58.3","","193.35","193.35","386.69","1 through 10","60.28","273.46","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.22","31.22","31.22","1 through 10","60.28","273.46","other","OPPS APC"
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.02","44.45","","155.36","155.36","155.36","1 through 10","60.28","273.46","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","351.00","263.25","WELLPOINT [1015]","HB CH WELLPOINT","273.46","77.91","","268.57","268.57","268.57","1 through 10","60.28","273.46","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","351.00","263.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.14","59.3","","199.83","195.05","199.83","17","90.37","275.36","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","275.36","78.45","","262.16","262.16","262.16","22","90.37","275.36","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","AETNA [1001]","HB CH AETNA HMO / PPO","119.52","58.3","","112.83","112.83","112.83","1 through 10","86.28","170.56","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","MEDICARE [2001]","HB NWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.54","76.54","153.08","22","86.28","170.56","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","75.01","75.01","150.02","1 through 10","86.28","170.56","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.12","44.45","","90.67","90.67","90.67","1 through 10","86.28","170.56","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.64","150.02","150.64","1 through 10","86.28","170.56","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","WELLPOINT [1015]","HB CH WELLPOINT","159.72","77.91","","753.73","156.73","753.73","1 through 10","86.28","170.56","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.82","78.45","","152.99","152.99","152.99","1 through 10","56.93","160.82","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","both","","","77.00","57.75","AETNA [1001]","HB CH AETNA HMO / PPO","44.89","58.3","","42.53","42.53","42.53","1 through 10","7.94","73.15","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","outpatient","","","77.00","57.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.66","59.3","","43.95","43.95","43.95","1 through 10","6.67","60.41","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.41","78.45","","57.66","57.66","57.66","1 through 10","6.67","60.41","percent of total billed charges",""
"Spectrophotometry","PX-30001469","CDM","84311","CPT","0301","RC","","","","both","","","77.00","57.75","AETNA [1001]","HB CH AETNA HMO / PPO","44.89","58.3","","42.53","42.53","42.53","1 through 10","7.94","73.15","percent of total billed charges",""
"Spectrophotometry","PX-30001469","CDM","84311","CPT","0301","RC","","","","outpatient","","","77.00","57.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.66","59.3","","43.95","43.95","43.95","1 through 10","6.67","60.41","percent of total billed charges",""
"Spectrophotometry","PX-30001469","CDM","84311","CPT","0301","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.41","78.45","","57.66","57.66","57.66","1 through 10","6.67","60.41","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1039.00","779.25","AETNA [1001]","HB CH AETNA HMO / PPO","605.74","58.3","","536.93","536.93","536.93","1 through 10","242.36","987.05","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1039.00","779.25","TRICARE [160005]","HB NWH TRICARE","987.05","95","","251.72","247.31","251.72","1 through 10","242.36","987.05","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1039.00","779.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","242.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($247.31). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($189.82). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","243.37","242.77","243.37","1 through 10","242.36","987.05","fee schedule",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","both","","","585.00","438.75","WELLPOINT [1015]","HB CH WELLPOINT","455.77","77.91","","448.14","448.14","448.14","1 through 10","62.18","555.75","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","outpatient","","","585.00","438.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.91","59.3","","333.43","322.92","333.43","1 through 10","90.37","458.93","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","outpatient","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","437.45","437.45","437.45","1 through 10","90.37","458.93","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","199.81","361.04","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","377.00","282.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","188.88","50.1","","2255.00","204.62","2255.00","1 through 10","167.58","567.68","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","1733.64","1733.64","1733.64","1 through 10","167.58","567.68","percent of total billed charges",""
"SPINAL BOLT 5X25MM MODULUS ALIF","SUP-ITM-10287121","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","5530.54","5530.54","5530.54","1 through 10","547.5","859.03","percent of total billed charges",""
"SPINAL CAGE 12X5MM TALOS C 7D LORDOTIC 12MM CERVICAL ANTERIOR PEEK OPTIMA HA FULL INTEGRATE ANGLE TEETH LG GRAFT WINDOW RADIO","SUP-ITM-10307547","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","5530.54","5530.54","5530.54","1 through 10","1050","1647.45","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","AETNA [1001]","HB CH AETNA HMO / PPO","2368.44","58.3","","2190.90","412.50","9264.59","16","1805.78","3165.09","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2356.25","58","","1903.20","1903.20","3826.66","1 through 10","1805.78","3165.09","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2539.06","62.5","","2186.25","2186.25","2186.25","32","1805.78","3165.09","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2965.63","73","","5556.60","5556.60","5556.60","1 through 10","1805.78","3165.09","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","WELLPOINT [1015]","HB CH WELLPOINT","3165.09","77.91","","1955.15","885.83","3150.40","26","1805.78","3165.09","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2409.06","59.3","","831.03","253.22","2394.88","18","2031.25","3187.03","percent of total billed charges",""
"SPINAL CAGE 14X15.5X5MM ROI-C LORDOTIC","SUP-ITM-10103550","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3187.03","78.45","","2481.69","1563.74","8149.28","1 through 10","2031.25","3187.03","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","AETNA [1001]","HB CH AETNA HMO / PPO","4314.20","58.3","","2190.90","412.50","9264.59","16","3289.3","5765.34","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4292.00","58","","1903.20","1903.20","3826.66","1 through 10","3289.3","5765.34","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4625.00","62.5","","2186.25","2186.25","2186.25","32","3289.3","5765.34","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5402.00","73","","5556.60","5556.60","5556.60","1 through 10","3289.3","5765.34","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","WELLPOINT [1015]","HB CH WELLPOINT","5765.34","77.91","","1955.15","885.83","3150.40","26","3289.3","5765.34","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4388.20","59.3","","831.03","253.22","2394.88","18","3700","5805.3","percent of total billed charges",""
"SPINAL CAGE 23X26X12MM 10DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5805.30","78.45","","2481.69","1563.74","8149.28","1 through 10","3700","5805.3","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","both","","","9450.00","7087.50","AETNA [1001]","HB CH AETNA HMO / PPO","5509.35","58.3","","2190.90","412.50","9264.59","16","4200.53","7362.5","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","both","","","9450.00","7087.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5481.00","58","","1903.20","1903.20","3826.66","1 through 10","4200.53","7362.5","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","both","","","9450.00","7087.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5906.25","62.5","","2186.25","2186.25","2186.25","32","4200.53","7362.5","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","both","","","9450.00","7087.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6898.50","73","","5556.60","5556.60","5556.60","1 through 10","4200.53","7362.5","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","both","","","9450.00","7087.50","WELLPOINT [1015]","HB CH WELLPOINT","7362.50","77.91","","1955.15","885.83","3150.40","26","4200.53","7362.5","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9450.00","7087.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5603.85","59.3","","831.03","253.22","2394.88","18","4725","7413.53","percent of total billed charges",""
"SPINAL CAGE 45X18X8-12MM 6DEG ACCELFIX-XL LATERAL TI-ALLOY/COLOR-ANODIZED EXPANDABLE L4518-0806S","SUP-ITM-10309004","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9450.00","7087.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7413.53","78.45","","2481.69","1563.74","8149.28","1 through 10","4725","7413.53","percent of total billed charges",""
"SPINAL CAGE 5X22.5MM MODULUS ALIF BOLT FIXATION","SUP-ITM-10287122","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","5530.54","5530.54","5530.54","1 through 10","547.5","859.03","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","2190.90","412.50","9264.59","16","193.36","338.91","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","252.30","58","","1903.20","1903.20","3826.66","1 through 10","193.36","338.91","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","271.88","62.5","","2186.25","2186.25","2186.25","32","193.36","338.91","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","5556.60","5556.60","5556.60","1 through 10","193.36","338.91","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","1955.15","885.83","3150.40","26","193.36","338.91","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","831.03","253.22","2394.88","18","217.5","341.26","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X25MM EXPEDIUM SFX TITANIUM OPEN LOW PROFILE","SUP-ITM-10048661","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","2481.69","1563.74","8149.28","1 through 10","217.5","341.26","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","2190.90","412.50","9264.59","16","593.41","1040.1","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","1903.20","1903.20","3826.66","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","2186.25","2186.25","2186.25","32","593.41","1040.1","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","5556.60","5556.60","5556.60","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","1955.15","885.83","3150.40","26","593.41","1040.1","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","831.03","253.22","2394.88","18","667.5","1047.31","percent of total billed charges",""
"SPINAL CONNECTOR 5.5X35MM LATERAL POLARIS","SUP-ITM-10048660","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","2481.69","1563.74","8149.28","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1320.00","990.00","AETNA [1001]","HB CH AETNA HMO / PPO","769.56","58.3","","2190.90","412.50","9264.59","16","586.74","1028.41","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","765.60","58","","1903.20","1903.20","3826.66","1 through 10","586.74","1028.41","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","825.00","62.5","","2186.25","2186.25","2186.25","32","586.74","1028.41","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1320.00","990.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","963.60","73","","5556.60","5556.60","5556.60","1 through 10","586.74","1028.41","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1320.00","990.00","WELLPOINT [1015]","HB CH WELLPOINT","1028.41","77.91","","1955.15","885.83","3150.40","26","586.74","1028.41","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","782.76","59.3","","831.03","253.22","2394.88","18","660","1035.54","percent of total billed charges",""
"SPINAL CONNECTOR LATERAL CHANNEL ROD","SUP-ITM-10175030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","2481.69","1563.74","8149.28","1 through 10","660","1035.54","percent of total billed charges",""
"Spinal Disorders And Injuries,MODERATE","040","DRG","","","","","","","","inpatient","","","28894.57","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","29600.79","","Fee schedule rate ($29,600.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29600.79","29600.79","29600.79","1 through 10","11804.57","37867.35","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","83752.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","70066.32","","Standard inlier is a Case rate ($70,066.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $83,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,946.19) for the length of stay and the standard reimbursement.","71844.05","71844.05","71844.05","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","83752.04","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","32584.3308","","Fee schedule rate ($69,819.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32584.3308","69819.66","69819.66","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","44502.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41962.33","","Standard inlier is a Case rate ($41,962.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,956.72) for the length of stay and the standard reimbursement.","41962.32","41962.32","41962.32","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","44502.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45075.91","","Standard inlier is a Case rate ($45,075.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,398.33) for the length of stay and the standard reimbursement.","45075.90","45075.90","45075.90","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","44502.99","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","35842.43","","Fee schedule rate ($35,842.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35842.43","35842.43","35842.43","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","44502.99","","MASSHEALTH [3001]","HB NWH MEDICAID","17846.04","","Case rate ($19,226.29). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $61,656.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19275.74","19275.74","19275.74","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","64130.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","50900.49","","Standard inlier is a Case rate ($50,900.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $63,865, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,225.52) for the length of stay and the standard reimbursement.","48595.32","48595.32","48595.32","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","64130.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","54677.28","","Standard inlier is a Case rate ($54,677.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $63,865, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,761.21) for the length of stay and the standard reimbursement.","54677.28","54677.28","54677.28","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","64130.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","32584.3308","","Fee schedule rate ($44,516.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32584.3308","44516.68","44516.68","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","64130.50","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","23682.25","","Fee schedule rate ($23,682.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23682.25","23682.25","23682.25","1 through 10","16952.47","313737.34","case rate",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","135052.04","101289.03","MEDICARE [2001]","HB NWH MEDICARE","56805.70","","Case rate ($56,805.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $53,072.81, add-ons for qualifying new technology services are included. If operating cost exceeds $98,215.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,890.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $52,857.60. The transfer operating threshold is the transfer adjustment factor * $53,072.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,948.10. The transfer capital threshold is the transfer adjustment factor * $3,948.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54777.80","54777.80","54876.29","1 through 10","50630.58","56805.7","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With McC","456","MS-DRG","","","","","","","","inpatient","","","122921.51","92191.13","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","74990.62","","Case rate ($72,806.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $74,791.98, add-ons for qualifying new technology services are included. If operating cost exceeds $119,934.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $8,505.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $67,242.64. The transfer operating threshold is the transfer adjustment factor * $74,791.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,563.79. The transfer capital threshold is the transfer adjustment factor * $5,563.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","75800.38","75800.38","75800.38","1 through 10","71350.3","83358.3366","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","71635.43","53726.57","MEDICARE [2001]","HB NWH MEDICARE","39749.04","","Case rate ($39,749.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $37,137, add-ons for qualifying new technology services are included. If operating cost exceeds $82,279.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,704.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $36,986.40. The transfer operating threshold is the transfer adjustment factor * $37,136.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,762.63. The transfer capital threshold is the transfer adjustment factor * $2,762.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41211.73","41211.73","41285.81","1 through 10","35428.08","42831.74","other","Inpatient DRG"
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","both","","","1760.00","1320.00","MEDICARE [2001]","HB NWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","175.28","350.56","1 through 10","333.03","1673.76","other","OPPS APC"
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","881.76","50.1","","2255.00","204.62","2255.00","1 through 10","567.68","1380.72","percent of total billed charges",""
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1380.72","78.45","","1733.64","1733.64","1733.64","1 through 10","567.68","1380.72","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","464.71","67.87","1012.10","221","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","293.04","293.04","293.04","11","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","983.89","983.89","983.89","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.60","58","","677.18","677.18","677.18","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.25","62.5","","46.58","46.58","46.58","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","747.15","747.15","747.15","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","1141.67","481.21","1141.67","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","76.54","76.54","76.54","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","273.64","94.28","1367.51","138","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","720.78","230.14","2010.94","427","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1049.61","59.3","","344.45","344.45","344.45","1 through 10","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","1120.13","1120.13","1120.13","1 through 10","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","456.17","105.33","1284.66","242","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","2190.90","412.50","9264.59","16","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1026.60","58","","1903.20","1903.20","3826.66","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1106.25","62.5","","2186.25","2186.25","2186.25","32","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","5556.60","5556.60","5556.60","1 through 10","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","1955.15","885.83","3150.40","26","786.77","1379.01","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","831.03","253.22","2394.88","18","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","2481.69","1563.74","8149.28","1 through 10","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","2190.90","412.50","9264.59","16","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","1903.20","1903.20","3826.66","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","2186.25","2186.25","2186.25","32","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","5556.60","5556.60","5556.60","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","1955.15","885.83","3150.40","26","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","831.03","253.22","2394.88","18","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","2481.69","1563.74","8149.28","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","464.71","67.87","1012.10","221","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","293.04","293.04","293.04","11","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","983.89","983.89","983.89","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","677.18","677.18","677.18","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","46.58","46.58","46.58","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","747.15","747.15","747.15","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","1141.67","481.21","1141.67","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","76.54","76.54","76.54","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","273.64","94.28","1367.51","138","900.11","1577.68","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","720.78","230.14","2010.94","427","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1200.83","59.3","","344.45","344.45","344.45","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","456.17","105.33","1284.66","242","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","AETNA [1001]","HB CH AETNA HMO / PPO","638.39","58.3","","464.71","67.87","1012.10","221","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","638.39","58.3","","293.04","293.04","293.04","11","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","580.35","53","","983.89","983.89","983.89","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","635.10","58","","677.18","677.18","677.18","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","684.38","62.5","","46.58","46.58","46.58","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","747.15","747.15","747.15","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","1141.67","481.21","1141.67","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","76.54","76.54","76.54","1 through 10","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","WELLPOINT [1015]","HB CH WELLPOINT","853.11","77.91","","273.64","94.28","1367.51","138","486.73","853.11","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","720.78","230.14","2010.94","427","547.5","859.03","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","649.34","59.3","","344.45","344.45","344.45","1 through 10","547.5","859.03","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","1120.13","1120.13","1120.13","1 through 10","547.5","859.03","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","456.17","105.33","1284.66","242","547.5","859.03","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","AETNA [1001]","HB CH AETNA HMO / PPO","1294.26","58.3","","464.71","67.87","1012.10","221","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1294.26","58.3","","293.04","293.04","293.04","11","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1176.60","53","","983.89","983.89","983.89","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1287.60","58","","677.18","677.18","677.18","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1387.50","62.5","","46.58","46.58","46.58","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","747.15","747.15","747.15","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","986.79","44.45","","1141.67","481.21","1141.67","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","986.79","44.45","","76.54","76.54","76.54","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","WELLPOINT [1015]","HB CH WELLPOINT","1729.60","77.91","","273.64","94.28","1367.51","138","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1316.46","59.3","","720.78","230.14","2010.94","427","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1316.46","59.3","","344.45","344.45","344.45","1 through 10","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","1120.13","1120.13","1120.13","1 through 10","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 60MM 4 LEVEL FIXED","SUP-ITM-10108097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","456.17","105.33","1284.66","242","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","AETNA [1001]","HB CH AETNA HMO / PPO","1294.26","58.3","","2190.90","412.50","9264.59","16","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1287.60","58","","1903.20","1903.20","3826.66","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1387.50","62.5","","2186.25","2186.25","2186.25","32","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","5556.60","5556.60","5556.60","1 through 10","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","WELLPOINT [1015]","HB CH WELLPOINT","1729.60","77.91","","1955.15","885.83","3150.40","26","986.79","1729.6","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1316.46","59.3","","831.03","253.22","2394.88","18","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 64MM CERVICAL 4 LEVEL MAXAN TITANIUM","SUP-ITM-10108098","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","2481.69","1563.74","8149.28","1 through 10","1110","1741.59","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","2190.90","412.50","9264.59","16","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","1903.20","1903.20","3826.66","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","2186.25","2186.25","2186.25","32","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","5556.60","5556.60","5556.60","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","1955.15","885.83","3150.40","26","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","831.03","253.22","2394.88","18","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 6MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104662","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","2481.69","1563.74","8149.28","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","464.71","67.87","1012.10","221","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","293.04","293.04","293.04","11","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","983.89","983.89","983.89","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","677.18","677.18","677.18","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","46.58","46.58","46.58","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","747.15","747.15","747.15","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1141.67","481.21","1141.67","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","76.54","76.54","76.54","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","273.64","94.28","1367.51","138","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","720.78","230.14","2010.94","427","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1645.58","59.3","","344.45","344.45","344.45","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","1120.13","1120.13","1120.13","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL CAUDAL ALTA TITANIUM HALF","SUP-ITM-10146102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","456.17","105.33","1284.66","242","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","2190.90","412.50","9264.59","16","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1609.50","58","","1903.20","1903.20","3826.66","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1734.38","62.5","","2186.25","2186.25","2186.25","32","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","5556.60","5556.60","5556.60","1 through 10","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","1955.15","885.83","3150.40","26","1233.49","2162","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","831.03","253.22","2394.88","18","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 7MM CERVICAL ZERO ALTA TITANIUM","SUP-ITM-10104663","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","2481.69","1563.74","8149.28","1 through 10","1387.5","2176.99","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","464.71","67.87","1012.10","221","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","293.04","293.04","293.04","11","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","983.89","983.89","983.89","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","677.18","677.18","677.18","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","46.58","46.58","46.58","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","747.15","747.15","747.15","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1141.67","481.21","1141.67","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","76.54","76.54","76.54","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","273.64","94.28","1367.51","138","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","720.78","230.14","2010.94","427","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","344.45","344.45","344.45","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1120.13","1120.13","1120.13","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","456.17","105.33","1284.66","242","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","464.71","67.87","1012.10","221","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","293.04","293.04","293.04","11","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","983.89","983.89","983.89","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","677.18","677.18","677.18","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","46.58","46.58","46.58","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","747.15","747.15","747.15","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1141.67","481.21","1141.67","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","76.54","76.54","76.54","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","273.64","94.28","1367.51","138","1866.9","3272.22","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","720.78","230.14","2010.94","427","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","344.45","344.45","344.45","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1120.13","1120.13","1120.13","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 8MM BUTTRESS TIMBERLINE TITANIUM 1 HOLE","SUP-ITM-10140304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","456.17","105.33","1284.66","242","2100","3294.9","percent of total billed charges",""
"Spinal Procedures With McC","028","MS-DRG","","","","","","","","inpatient","","","103372.12","77529.09","MEDICARE [2001]","HB NWH MEDICARE","57236.28","","Case rate ($57,236.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $53,475.10, add-ons for qualifying new technology services are included. If operating cost exceeds $98,617.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,919.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $53,258.26. The transfer operating threshold is the transfer adjustment factor * $53,475.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,978.03. The transfer capital threshold is the transfer adjustment factor * $3,978.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43813.74","43813.74","58128.10","1 through 10","51014.35","59592.1029","other","Inpatient DRG"
"Spinal Procedures Without Cc/McC","030","MS-DRG","","","","","","","","inpatient","","","70374.77","52781.08","MEDICARE [2001]","HB NWH MEDICARE","19019.06","","Case rate ($19,019.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $19,537.73, add-ons for qualifying new technology services are included. If operating cost exceeds $64,680.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,395.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,565.63. The transfer operating threshold is the transfer adjustment factor * $19,537.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,453.42. The transfer capital threshold is the transfer adjustment factor * $1,453.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21277.79","21277.79","21277.79","1 through 10","18638.68","22006.9806","other","Inpatient Replacement Plans DRG"
"Spinal Procedures,MINOR","023","DRG","","","","","","","","inpatient","","","70374.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40388.46","","Standard inlier is a Case rate ($40,388.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $50,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,732.97) for the length of stay and the standard reimbursement.","40388.45","40388.45","40388.45","1 through 10","2757","69921.11","case rate",""
"Spinal Procedures,MODERATE","023","DRG","","","","","","","","inpatient","","","92602.84","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","34539.6327","","Fee schedule rate ($44,495.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34539.6327","123487.81","123487.81","1 through 10","2757","69921.11","case rate",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","2190.90","412.50","9264.59","16","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","1903.20","1903.20","3826.66","1 through 10","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","2186.25","2186.25","2186.25","32","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","5556.60","5556.60","5556.60","1 through 10","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","1955.15","885.83","3150.40","26","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","831.03","253.22","2394.88","18","360","564.84","percent of total billed charges",""
"SPINAL ROD 3.5X180MM LINEUM TITANIUM","SUP-ITM-10108107","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","2481.69","1563.74","8149.28","1 through 10","360","564.84","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","2190.90","412.50","9264.59","16","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","1903.20","1903.20","3826.66","1 through 10","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","2186.25","2186.25","2186.25","32","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","5556.60","5556.60","5556.60","1 through 10","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","1955.15","885.83","3150.40","26","320.04","560.95","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","831.03","253.22","2394.88","18","360","564.84","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","2481.69","1563.74","8149.28","1 through 10","360","564.84","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","both","","","642.00","481.50","AETNA [1001]","HB CH AETNA HMO / PPO","374.29","58.3","","2190.90","412.50","9264.59","16","285.37","500.18","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","both","","","642.00","481.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","372.36","58","","1903.20","1903.20","3826.66","1 through 10","285.37","500.18","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","both","","","642.00","481.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","401.25","62.5","","2186.25","2186.25","2186.25","32","285.37","500.18","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","both","","","642.00","481.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","468.66","73","","5556.60","5556.60","5556.60","1 through 10","285.37","500.18","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","both","","","642.00","481.50","WELLPOINT [1015]","HB CH WELLPOINT","500.18","77.91","","1955.15","885.83","3150.40","26","285.37","500.18","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","642.00","481.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","380.71","59.3","","831.03","253.22","2394.88","18","321","503.65","percent of total billed charges",""
"SPINAL ROD 45MM PERCUTANEOUS PRE BENT PATHFINDER","SUP-ITM-10108509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","642.00","481.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","503.65","78.45","","2481.69","1563.74","8149.28","1 through 10","321","503.65","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","2190.90","412.50","9264.59","16","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3480.00","58","","1903.20","1903.20","3826.66","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3750.00","62.5","","2186.25","2186.25","2186.25","32","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","5556.60","5556.60","5556.60","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","1955.15","885.83","3150.40","26","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","831.03","253.22","2394.88","18","3000","4707","percent of total billed charges",""
"SPINAL SPACER 10X28MM 8-13MM 12DEG EXPANDABLE PROLIFT","SUP-ITM-10267900","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","2481.69","1563.74","8149.28","1 through 10","3000","4707","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","2190.90","412.50","9264.59","16","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3480.00","58","","1903.20","1903.20","3826.66","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3750.00","62.5","","2186.25","2186.25","2186.25","32","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","5556.60","5556.60","5556.60","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","1955.15","885.83","3150.40","26","2667","4674.6","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","831.03","253.22","2394.88","18","3000","4707","percent of total billed charges",""
"SPINAL SPACER 10X30MM 10-17MM 15DEG LORDOTIC RISE","SUP-ITM-10137682","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","2481.69","1563.74","8149.28","1 through 10","3000","4707","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","2190.90","412.50","9264.59","16","933.45","1636.11","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","1903.20","1903.20","3826.66","1 through 10","933.45","1636.11","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","2186.25","2186.25","2186.25","32","933.45","1636.11","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","5556.60","5556.60","5556.60","1 through 10","933.45","1636.11","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1955.15","885.83","3150.40","26","933.45","1636.11","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","831.03","253.22","2394.88","18","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM ALLOGRAFT LORDOTIC CERVICAL","SUP-ITM-10036477","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2481.69","1563.74","8149.28","1 through 10","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","AETNA [1001]","HB CH AETNA HMO / PPO","1504.14","58.3","","2190.90","412.50","9264.59","16","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1496.40","58","","1903.20","1903.20","3826.66","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1612.50","62.5","","2186.25","2186.25","2186.25","32","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1883.40","73","","5556.60","5556.60","5556.60","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","WELLPOINT [1015]","HB CH WELLPOINT","2010.08","77.91","","1955.15","885.83","3150.40","26","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1529.94","59.3","","831.03","253.22","2394.88","18","1290","2024.01","percent of total billed charges",""
"SPINAL SPACER 13X15 7MM 5DEG ANTERIOR CERVICAL DISECTOMY FUSION PEEK 8411-0507","SUP-ITM-10104648","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","2481.69","1563.74","8149.28","1 through 10","1290","2024.01","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","AETNA [1001]","HB CH AETNA HMO / PPO","1504.14","58.3","","2190.90","412.50","9264.59","16","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1496.40","58","","1903.20","1903.20","3826.66","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1612.50","62.5","","2186.25","2186.25","2186.25","32","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1883.40","73","","5556.60","5556.60","5556.60","1 through 10","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","both","","","2580.00","1935.00","WELLPOINT [1015]","HB CH WELLPOINT","2010.08","77.91","","1955.15","885.83","3150.40","26","1146.81","2010.08","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1529.94","59.3","","831.03","253.22","2394.88","18","1290","2024.01","percent of total billed charges",""
"SPINAL SPACER 14X17X7MM CERVICAL ANTERIOR POLYETHER ETHER KETONE 5 DEG 8412-0507","SUP-ITM-10104658","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2580.00","1935.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2024.01","78.45","","2481.69","1563.74","8149.28","1 through 10","1290","2024.01","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","AETNA [1001]","HB CH AETNA HMO / PPO","4343.35","58.3","","2190.90","412.50","9264.59","16","3311.53","5804.3","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4321.00","58","","1903.20","1903.20","3826.66","1 through 10","3311.53","5804.3","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4656.25","62.5","","2186.25","2186.25","2186.25","32","3311.53","5804.3","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5438.50","73","","5556.60","5556.60","5556.60","1 through 10","3311.53","5804.3","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","WELLPOINT [1015]","HB CH WELLPOINT","5804.30","77.91","","1955.15","885.83","3150.40","26","3311.53","5804.3","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","831.03","253.22","2394.88","18","3725","5844.53","percent of total billed charges",""
"SPINAL SPACER 18X45MM 10 8DEG CAGE LORDOTICDOSIS","SUP-ITM-10104490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5844.53","78.45","","2481.69","1563.74","8149.28","1 through 10","3725","5844.53","percent of total billed charges",""
"SPINAL SPACER 7MM CATALYFT PL LONG","SUP-ITM-10307453","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","10400.00","7800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6167.20","59.3","","5530.54","5530.54","5530.54","1 through 10","5200","8158.8","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","2190.90","412.50","9264.59","16","1866.9","3272.22","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","1903.20","1903.20","3826.66","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","2186.25","2186.25","2186.25","32","1866.9","3272.22","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","5556.60","5556.60","5556.60","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","1955.15","885.83","3150.40","26","1866.9","3272.22","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","831.03","253.22","2394.88","18","2100","3294.9","percent of total billed charges",""
"SPINAL SPACER 9X27MM 6DEG PEEK LORDOTIC CURVE ZYSTON","SUP-ITM-10108187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","2481.69","1563.74","8149.28","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE CAGE 10DEGREE 10MM MED ANTERIOR SECURED LUMBAR LORDOSIS","SUP-ITM-10236152","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4388.20","59.3","","5530.54","5530.54","5530.54","1 through 10","3700","5805.3","percent of total billed charges",""
"SPINE CAGE 10X10X30MM 12DEG MODULUS TLIF-O","SUP-ITM-10212235","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","5530.54","5530.54","5530.54","1 through 10","3000","4707","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","2190.90","412.50","9264.59","16","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","1903.20","1903.20","3826.66","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","2186.25","2186.25","2186.25","32","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","5556.60","5556.60","5556.60","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","1955.15","885.83","3150.40","26","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","831.03","253.22","2394.88","18","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","2481.69","1563.74","8149.28","1 through 10","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 10X22X60MM 15DEG MODULUS XLW","SUP-ITM-10212256","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9200.00","6900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5455.60","59.3","","5530.54","5530.54","5530.54","1 through 10","4600","7217.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","2190.90","412.50","9264.59","16","1778","3116.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","1903.20","1903.20","3826.66","1 through 10","1778","3116.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","2186.25","2186.25","2186.25","32","1778","3116.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","5556.60","5556.60","5556.60","1 through 10","1778","3116.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1955.15","885.83","3150.40","26","1778","3116.4","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","831.03","253.22","2394.88","18","2000","3138","percent of total billed charges",""
"SPINE CAGE 11X9X27MM STRAIGHT FORZA POLYETHER ETHER KETONE TITANIUM 8 DEG","SUP-ITM-10110502","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2481.69","1563.74","8149.28","1 through 10","2000","3138","percent of total billed charges",""
"SPINE CAGE 12X14X5MM CERVICAL SURGICAL","SUP-ITM-10170879","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","5530.54","5530.54","5530.54","1 through 10","1050","1647.45","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","AETNA [1001]","HB CH AETNA HMO / PPO","4314.20","58.3","","2190.90","412.50","9264.59","16","3289.3","5765.34","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4292.00","58","","1903.20","1903.20","3826.66","1 through 10","3289.3","5765.34","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4625.00","62.5","","2186.25","2186.25","2186.25","32","3289.3","5765.34","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5402.00","73","","5556.60","5556.60","5556.60","1 through 10","3289.3","5765.34","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","WELLPOINT [1015]","HB CH WELLPOINT","5765.34","77.91","","1955.15","885.83","3150.40","26","3289.3","5765.34","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4388.20","59.3","","831.03","253.22","2394.88","18","3700","5805.3","percent of total billed charges",""
"SPINE CAGE 12X32X26MM LUMBAR 12 DEG","SUP-ITM-10192043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5805.30","78.45","","2481.69","1563.74","8149.28","1 through 10","3700","5805.3","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","2190.90","412.50","9264.59","16","933.45","1636.11","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1218.00","58","","1903.20","1903.20","3826.66","1 through 10","933.45","1636.11","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1312.50","62.5","","2186.25","2186.25","2186.25","32","933.45","1636.11","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","5556.60","5556.60","5556.60","1 through 10","933.45","1636.11","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","1955.15","885.83","3150.40","26","933.45","1636.11","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","831.03","253.22","2394.88","18","1050","1647.45","percent of total billed charges",""
"SPINE CAGE 14X11X6MM ANATOMIC PEEK PTC DISPOSABLE","SUP-ITM-10259900","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2481.69","1563.74","8149.28","1 through 10","1050","1647.45","percent of total billed charges",""
"SPINE CAGE 22.0X8.0MM 5DEG JULIET PO PEEK POSTERIOR LUMBAR INTERBODY FUSION","SUP-ITM-10108673","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","5530.54","5530.54","5530.54","1 through 10","2000","3138","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","2190.90","412.50","9264.59","16","166.69","292.16","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","217.50","58","","1903.20","1903.20","3826.66","1 through 10","166.69","292.16","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","234.38","62.5","","2186.25","2186.25","2186.25","32","166.69","292.16","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","both","","","375.00","281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","5556.60","5556.60","5556.60","1 through 10","166.69","292.16","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","both","","","375.00","281.25","WELLPOINT [1015]","HB CH WELLPOINT","292.16","77.91","","1955.15","885.83","3150.40","26","166.69","292.16","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","831.03","253.22","2394.88","18","187.5","294.19","percent of total billed charges",""
"SPINE CAGE 4.5X20MM LUMBAR ANTERIOR RAMPART ONE FUSION","SUP-ITM-10192018","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","2481.69","1563.74","8149.28","1 through 10","187.5","294.19","percent of total billed charges",""
"SPINE CAGE 40X10MM LUMBAR LATERAL JULIET POLYETHER ETHER KETONE","SUP-ITM-10131731","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","5530.54","5530.54","5530.54","1 through 10","3725","5844.53","percent of total billed charges",""
"SPINE CAGE 55X14MM LUMBAR LATERAL JULIET POLYETHER ETHER KETONE","SUP-ITM-10131748","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","5530.54","5530.54","5530.54","1 through 10","3725","5844.53","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","AETNA [1001]","HB CH AETNA HMO / PPO","2368.44","58.3","","2190.90","412.50","9264.59","16","1805.78","3165.09","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2356.25","58","","1903.20","1903.20","3826.66","1 through 10","1805.78","3165.09","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2539.06","62.5","","2186.25","2186.25","2186.25","32","1805.78","3165.09","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2965.63","73","","5556.60","5556.60","5556.60","1 through 10","1805.78","3165.09","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4062.50","3046.87","WELLPOINT [1015]","HB CH WELLPOINT","3165.09","77.91","","1955.15","885.83","3150.40","26","1805.78","3165.09","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2409.06","59.3","","831.03","253.22","2394.88","18","2031.25","3187.03","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3187.03","78.45","","2481.69","1563.74","8149.28","1 through 10","2031.25","3187.03","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","464.71","67.87","1012.10","221","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2565.20","58.3","","293.04","293.04","293.04","11","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2332.00","53","","983.89","983.89","983.89","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","677.18","677.18","677.18","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","46.58","46.58","46.58","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","747.15","747.15","747.15","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","1141.67","481.21","1141.67","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","76.54","76.54","76.54","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","273.64","94.28","1367.51","138","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","720.78","230.14","2010.94","427","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2609.20","59.3","","344.45","344.45","344.45","1 through 10","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","1120.13","1120.13","1120.13","1 through 10","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","456.17","105.33","1284.66","242","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","464.71","67.87","1012.10","221","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2565.20","58.3","","293.04","293.04","293.04","11","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2332.00","53","","983.89","983.89","983.89","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","677.18","677.18","677.18","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","46.58","46.58","46.58","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","747.15","747.15","747.15","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","1141.67","481.21","1141.67","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","76.54","76.54","76.54","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","273.64","94.28","1367.51","138","1955.8","3428.04","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","720.78","230.14","2010.94","427","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2609.20","59.3","","344.45","344.45","344.45","1 through 10","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","1120.13","1120.13","1120.13","1 through 10","2200","3451.8","percent of total billed charges",""
"SPINE CAGE 9X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","456.17","105.33","1284.66","242","2200","3451.8","percent of total billed charges",""
"SPINE CAGE ANCHOR 6.0X14.0 16.0MM 4DEG ADVANCED VIDEO SYSTEM C PEEK ANTERIOR CERVICAL","SUP-ITM-10106976","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","4062.50","3046.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2409.06","59.3","","5530.54","5530.54","5530.54","1 through 10","2031.25","3187.03","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","AETNA [1001]","HB CH AETNA HMO / PPO","4926.35","58.3","","464.71","67.87","1012.10","221","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4926.35","58.3","","293.04","293.04","293.04","11","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4478.50","53","","983.89","983.89","983.89","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4901.00","58","","677.18","677.18","677.18","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5281.25","62.5","","46.58","46.58","46.58","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6168.50","73","","747.15","747.15","747.15","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3756.03","44.45","","1141.67","481.21","1141.67","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3756.03","44.45","","76.54","76.54","76.54","1 through 10","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","both","","","8450.00","6337.50","WELLPOINT [1015]","HB CH WELLPOINT","6583.40","77.91","","273.64","94.28","1367.51","138","3756.03","6583.4","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8450.00","6337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5010.85","59.3","","720.78","230.14","2010.94","427","4225","6629.03","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8450.00","6337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5010.85","59.3","","344.45","344.45","344.45","1 through 10","4225","6629.03","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8450.00","6337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","6629.03","78.45","","1120.13","1120.13","1120.13","1 through 10","4225","6629.03","percent of total billed charges",""
"SPINE CAGE CORPECTOMY 12 X 14 MM 18-21MM 0DEGREE W/SET SCREW","SUP-ITM-10330114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8450.00","6337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6629.03","78.45","","456.17","105.33","1284.66","242","4225","6629.03","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","2190.90","412.50","9264.59","16","193.36","338.91","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","252.30","58","","1903.20","1903.20","3826.66","1 through 10","193.36","338.91","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","271.88","62.5","","2186.25","2186.25","2186.25","32","193.36","338.91","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","5556.60","5556.60","5556.60","1 through 10","193.36","338.91","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","1955.15","885.83","3150.40","26","193.36","338.91","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","831.03","253.22","2394.88","18","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR 23MM CROSS FIXED","SUP-ITM-10083533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","2481.69","1563.74","8149.28","1 through 10","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","2190.90","412.50","9264.59","16","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","1903.20","1903.20","3826.66","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","2186.25","2186.25","2186.25","32","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","5556.60","5556.60","5556.60","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","1955.15","885.83","3150.40","26","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","831.03","253.22","2394.88","18","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 5.5MM MOUNTAINEER AXIAL","SUP-ITM-10020624","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","2481.69","1563.74","8149.28","1 through 10","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","AETNA [1001]","HB CH AETNA HMO / PPO","848.27","58.3","","2190.90","412.50","9264.59","16","646.75","1133.59","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","843.90","58","","1903.20","1903.20","3826.66","1 through 10","646.75","1133.59","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","909.38","62.5","","2186.25","2186.25","2186.25","32","646.75","1133.59","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","5556.60","5556.60","5556.60","1 through 10","646.75","1133.59","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","WELLPOINT [1015]","HB CH WELLPOINT","1133.59","77.91","","1955.15","885.83","3150.40","26","646.75","1133.59","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.82","59.3","","831.03","253.22","2394.88","18","727.5","1141.45","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","2481.69","1563.74","8149.28","1 through 10","727.5","1141.45","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","2190.90","412.50","9264.59","16","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","1903.20","1903.20","3826.66","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","2186.25","2186.25","2186.25","32","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","5556.60","5556.60","5556.60","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","1955.15","885.83","3150.40","26","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","831.03","253.22","2394.88","18","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","2481.69","1563.74","8149.28","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","2190.90","412.50","9264.59","16","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","1903.20","1903.20","3826.66","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","2186.25","2186.25","2186.25","32","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","5556.60","5556.60","5556.60","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","1955.15","885.83","3150.40","26","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","831.03","253.22","2394.88","18","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 6.35 TO 5.5MM TITANIUM AXIAL","SUP-ITM-10079554","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","2481.69","1563.74","8149.28","1 through 10","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","2190.90","412.50","9264.59","16","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","1903.20","1903.20","3826.66","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","2186.25","2186.25","2186.25","32","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","5556.60","5556.60","5556.60","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","1955.15","885.83","3150.40","26","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","831.03","253.22","2394.88","18","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 60MM CROSS FIX","SUP-ITM-10083525","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","2481.69","1563.74","8149.28","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","464.71","67.87","1012.10","221","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","293.04","293.04","293.04","11","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","983.89","983.89","983.89","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","435.00","58","","677.18","677.18","677.18","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","468.75","62.5","","46.58","46.58","46.58","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","747.15","747.15","747.15","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","1141.67","481.21","1141.67","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","76.54","76.54","76.54","1 through 10","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","273.64","94.28","1367.51","138","333.38","584.33","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","720.78","230.14","2010.94","427","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","444.75","59.3","","344.45","344.45","344.45","1 through 10","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1120.13","1120.13","1120.13","1 through 10","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR PARALLEL","SUP-ITM-10158796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","456.17","105.33","1284.66","242","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","2190.90","412.50","9264.59","16","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","1903.20","1903.20","3826.66","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","2186.25","2186.25","2186.25","32","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","5556.60","5556.60","5556.60","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","1955.15","885.83","3150.40","26","593.41","1040.1","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","831.03","253.22","2394.88","18","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","2481.69","1563.74","8149.28","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","AETNA [1001]","HB CH AETNA HMO / PPO","5458.05","58.3","","2190.90","412.50","9264.59","16","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5429.96","58","","1903.20","1903.20","3826.66","1 through 10","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5851.25","62.5","","2186.25","2186.25","2186.25","32","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6834.26","73","","5556.60","5556.60","5556.60","1 through 10","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","WELLPOINT [1015]","HB CH WELLPOINT","7293.93","77.91","","1955.15","885.83","3150.40","26","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5551.67","59.3","","831.03","253.22","2394.88","18","4681","7344.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING LG 09.820.055S","SUP-ITM-10050575","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7344.49","78.45","","2481.69","1563.74","8149.28","1 through 10","4681","7344.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","AETNA [1001]","HB CH AETNA HMO / PPO","5458.05","58.3","","2190.90","412.50","9264.59","16","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5429.96","58","","1903.20","1903.20","3826.66","1 through 10","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5851.25","62.5","","2186.25","2186.25","2186.25","32","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6834.26","73","","5556.60","5556.60","5556.60","1 through 10","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","WELLPOINT [1015]","HB CH WELLPOINT","7293.93","77.91","","1955.15","885.83","3150.40","26","4161.41","7293.93","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5551.67","59.3","","831.03","253.22","2394.88","18","4681","7344.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7344.49","78.45","","2481.69","1563.74","8149.28","1 through 10","4681","7344.49","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","AETNA [1001]","HB CH AETNA HMO / PPO","4880.88","58.3","","2190.90","412.50","9264.59","16","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4855.76","58","","1903.20","1903.20","3826.66","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5232.50","62.5","","2186.25","2186.25","2186.25","32","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6111.56","73","","5556.60","5556.60","5556.60","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","WELLPOINT [1015]","HB CH WELLPOINT","6522.63","77.91","","1955.15","885.83","3150.40","26","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4964.60","59.3","","831.03","253.22","2394.88","18","4186","6567.83","percent of total billed charges",""
"SPINE ENDPLATE MED 3DEG SUPERIOR PRODISC-L","SUP-ITM-10280272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6567.83","78.45","","2481.69","1563.74","8149.28","1 through 10","4186","6567.83","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","AETNA [1001]","HB CH AETNA HMO / PPO","4880.88","58.3","","2190.90","412.50","9264.59","16","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4855.76","58","","1903.20","1903.20","3826.66","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5232.50","62.5","","2186.25","2186.25","2186.25","32","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6111.56","73","","5556.60","5556.60","5556.60","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","WELLPOINT [1015]","HB CH WELLPOINT","6522.63","77.91","","1955.15","885.83","3150.40","26","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4964.60","59.3","","831.03","253.22","2394.88","18","4186","6567.83","percent of total billed charges",""
"SPINE ENDPLATE MED 8DEG INFERIOR PRODISC-L","SUP-ITM-10280273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6567.83","78.45","","2481.69","1563.74","8149.28","1 through 10","4186","6567.83","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","AETNA [1001]","HB CH AETNA HMO / PPO","4880.88","58.3","","2190.90","412.50","9264.59","16","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4855.76","58","","1903.20","1903.20","3826.66","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5232.50","62.5","","2186.25","2186.25","2186.25","32","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6111.56","73","","5556.60","5556.60","5556.60","1 through 10","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","both","","","8372.00","6279.00","WELLPOINT [1015]","HB CH WELLPOINT","6522.63","77.91","","1955.15","885.83","3150.40","26","3721.35","6522.63","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4964.60","59.3","","831.03","253.22","2394.88","18","4186","6567.83","percent of total billed charges",""
"SPINE ENDPLATE MED PRODISC L TI INFERIOR","SUP-ITM-10080577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8372.00","6279.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6567.83","78.45","","2481.69","1563.74","8149.28","1 through 10","4186","6567.83","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","AETNA [1001]","HB CH AETNA HMO / PPO","5470.87","58.3","","464.71","67.87","1012.10","221","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5470.87","58.3","","293.04","293.04","293.04","11","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4973.52","53","","983.89","983.89","983.89","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5442.72","58","","677.18","677.18","677.18","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5865.00","62.5","","46.58","46.58","46.58","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6850.32","73","","747.15","747.15","747.15","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4171.19","44.45","","1141.67","481.21","1141.67","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4171.19","44.45","","76.54","76.54","76.54","1 through 10","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","both","","","9384.00","7038.00","WELLPOINT [1015]","HB CH WELLPOINT","7311.07","77.91","","273.64","94.28","1367.51","138","4171.19","7311.07","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9384.00","7038.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5564.71","59.3","","720.78","230.14","2010.94","427","4692","7361.75","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9384.00","7038.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5564.71","59.3","","344.45","344.45","344.45","1 through 10","4692","7361.75","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9384.00","7038.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7361.75","78.45","","1120.13","1120.13","1120.13","1 through 10","4692","7361.75","percent of total billed charges",""
"SPINE IMPLANT 6MM MED LONG DISC M6-C","SUP-ITM-10273951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9384.00","7038.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7361.75","78.45","","456.17","105.33","1284.66","242","4692","7361.75","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","AETNA [1001]","HB CH AETNA HMO / PPO","5363.60","58.3","","2190.90","412.50","9264.59","16","4089.4","7167.72","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5336.00","58","","1903.20","1903.20","3826.66","1 through 10","4089.4","7167.72","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5750.00","62.5","","2186.25","2186.25","2186.25","32","4089.4","7167.72","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6716.00","73","","5556.60","5556.60","5556.60","1 through 10","4089.4","7167.72","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","WELLPOINT [1015]","HB CH WELLPOINT","7167.72","77.91","","1955.15","885.83","3150.40","26","4089.4","7167.72","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9200.00","6900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5455.60","59.3","","831.03","253.22","2394.88","18","4600","7217.4","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 15 DEG","SUP-ITM-10187952","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9200.00","6900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7217.40","78.45","","2481.69","1563.74","8149.28","1 through 10","4600","7217.4","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","AETNA [1001]","HB CH AETNA HMO / PPO","1287.26","58.3","","2190.90","412.50","9264.59","16","981.46","1720.25","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1280.64","58","","1903.20","1903.20","3826.66","1 through 10","981.46","1720.25","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1380.00","62.5","","2186.25","2186.25","2186.25","32","981.46","1720.25","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1611.84","73","","5556.60","5556.60","5556.60","1 through 10","981.46","1720.25","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","both","","","2208.00","1656.00","WELLPOINT [1015]","HB CH WELLPOINT","1720.25","77.91","","1955.15","885.83","3150.40","26","981.46","1720.25","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2208.00","1656.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1309.34","59.3","","831.03","253.22","2394.88","18","1104","1732.18","percent of total billed charges",""
"SPINE INLAY 10MM MED PRODISC L POLYETHYLENE WITH MARKER TANTALUM","SUP-ITM-10082866","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2208.00","1656.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1732.18","78.45","","2481.69","1563.74","8149.28","1 through 10","1104","1732.18","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","AETNA [1001]","HB CH AETNA HMO / PPO","3614.60","58.3","","2190.90","412.50","9264.59","16","2755.9","4830.42","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3596.00","58","","1903.20","1903.20","3826.66","1 through 10","2755.9","4830.42","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3875.00","62.5","","2186.25","2186.25","2186.25","32","2755.9","4830.42","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4526.00","73","","5556.60","5556.60","5556.60","1 through 10","2755.9","4830.42","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB CH WELLPOINT","4830.42","77.91","","1955.15","885.83","3150.40","26","2755.9","4830.42","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3676.60","59.3","","831.03","253.22","2394.88","18","3100","4863.9","percent of total billed charges",""
"SPINE INTERBODY SM FUSION SYSTEM OPTIMESH","SUP-ITM-10282599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4863.90","78.45","","2481.69","1563.74","8149.28","1 through 10","3100","4863.9","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","464.71","67.87","1012.10","221","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","647.13","58.3","","293.04","293.04","293.04","11","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","588.30","53","","983.89","983.89","983.89","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","643.80","58","","677.18","677.18","677.18","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","693.75","62.5","","46.58","46.58","46.58","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","747.15","747.15","747.15","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","1141.67","481.21","1141.67","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","76.54","76.54","76.54","1 through 10","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","WELLPOINT [1015]","HB CH WELLPOINT","864.80","77.91","","273.64","94.28","1367.51","138","493.4","864.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","720.78","230.14","2010.94","427","555","870.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","658.23","59.3","","344.45","344.45","344.45","1 through 10","555","870.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","1120.13","1120.13","1120.13","1 through 10","555","870.8","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","456.17","105.33","1284.66","242","555","870.8","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","464.71","67.87","1012.10","221","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","293.04","293.04","293.04","11","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","983.89","983.89","983.89","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","677.18","677.18","677.18","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","46.58","46.58","46.58","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","747.15","747.15","747.15","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1141.67","481.21","1141.67","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","76.54","76.54","76.54","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","273.64","94.28","1367.51","138","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","720.78","230.14","2010.94","427","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","344.45","344.45","344.45","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1120.13","1120.13","1120.13","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM MODULES XL IF","SUP-ITM-10252438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","456.17","105.33","1284.66","242","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","464.71","67.87","1012.10","221","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","293.04","293.04","293.04","11","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","983.89","983.89","983.89","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2436.00","58","","677.18","677.18","677.18","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2625.00","62.5","","46.58","46.58","46.58","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","747.15","747.15","747.15","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","1141.67","481.21","1141.67","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","76.54","76.54","76.54","1 through 10","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","273.64","94.28","1367.51","138","1866.9","3272.22","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","720.78","230.14","2010.94","427","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2490.60","59.3","","344.45","344.45","344.45","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1120.13","1120.13","1120.13","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 10MM TITANIUM SKYHAWK BONE THORACOLUMBAR LATERAL","SUP-ITM-10173840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","456.17","105.33","1284.66","242","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 12MM XLIF MODULUS DUAL SIDED MOD","SUP-ITM-10275378","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","5530.54","5530.54","5530.54","1 through 10","2100","3294.9","percent of total billed charges",""
"SPINE PLATE 26MM LEVEL 1","SUP-ITM-10175782","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","5530.54","5530.54","5530.54","1 through 10","750","1176.75","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","464.71","67.87","1012.10","221","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1486.65","58.3","","293.04","293.04","293.04","11","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1351.50","53","","983.89","983.89","983.89","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1479.00","58","","677.18","677.18","677.18","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1593.75","62.5","","46.58","46.58","46.58","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","747.15","747.15","747.15","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","1141.67","481.21","1141.67","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","76.54","76.54","76.54","1 through 10","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","273.64","94.28","1367.51","138","1133.48","1986.71","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","720.78","230.14","2010.94","427","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1512.15","59.3","","344.45","344.45","344.45","1 through 10","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","1120.13","1120.13","1120.13","1 through 10","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","456.17","105.33","1284.66","242","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","464.71","67.87","1012.10","221","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","778.31","58.3","","293.04","293.04","293.04","11","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","707.55","53","","983.89","983.89","983.89","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","677.18","677.18","677.18","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","46.58","46.58","46.58","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","747.15","747.15","747.15","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","1141.67","481.21","1141.67","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","76.54","76.54","76.54","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","273.64","94.28","1367.51","138","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","720.78","230.14","2010.94","427","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","791.66","59.3","","344.45","344.45","344.45","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1120.13","1120.13","1120.13","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 4.75X47MM 60 CROSSLINK SOLERA TITANIUM MULTISPAN","SUP-ITM-10089026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","456.17","105.33","1284.66","242","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 46MM CERVICAL 2 LEVEL 6 HOLE","SUP-ITM-10184581","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","5530.54","5530.54","5530.54","1 through 10","885","1388.57","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","464.71","67.87","1012.10","221","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","778.31","58.3","","293.04","293.04","293.04","11","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","707.55","53","","983.89","983.89","983.89","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","677.18","677.18","677.18","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","46.58","46.58","46.58","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","747.15","747.15","747.15","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","1141.67","481.21","1141.67","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","76.54","76.54","76.54","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","273.64","94.28","1367.51","138","593.41","1040.1","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","720.78","230.14","2010.94","427","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","791.66","59.3","","344.45","344.45","344.45","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1120.13","1120.13","1120.13","1 through 10","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 5.5X39.6 TO 44.5MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10014064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","456.17","105.33","1284.66","242","667.5","1047.31","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","2190.90","412.50","9264.59","16","900.11","1577.68","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","1903.20","1903.20","3826.66","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","2186.25","2186.25","2186.25","32","900.11","1577.68","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","5556.60","5556.60","5556.60","1 through 10","900.11","1577.68","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","1955.15","885.83","3150.40","26","900.11","1577.68","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","831.03","253.22","2394.88","18","1012.5","1588.61","percent of total billed charges",""
"SPINE PLATE 54MM CERVICAL ANTERIOR CETRA 3 LEVEL","SUP-ITM-10188512","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","2481.69","1563.74","8149.28","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","both","","","10908.00","8181.00","AETNA [1001]","HB CH AETNA HMO / PPO","6359.36","58.3","","2190.90","412.50","9264.59","16","4848.61","8498.42","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","both","","","10908.00","8181.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6326.64","58","","1903.20","1903.20","3826.66","1 through 10","4848.61","8498.42","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","both","","","10908.00","8181.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6817.50","62.5","","2186.25","2186.25","2186.25","32","4848.61","8498.42","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","both","","","10908.00","8181.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7962.84","73","","5556.60","5556.60","5556.60","1 through 10","4848.61","8498.42","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","both","","","10908.00","8181.00","WELLPOINT [1015]","HB CH WELLPOINT","8498.42","77.91","","1955.15","885.83","3150.40","26","4848.61","8498.42","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10908.00","8181.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6468.44","59.3","","831.03","253.22","2394.88","18","5454","8557.33","percent of total billed charges",""
"SPINE PLATE 6.0X16MM PRESTIGE TITANIUM LOW PROFILE CERVICAL","SUP-ITM-10177843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10908.00","8181.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8557.33","78.45","","2481.69","1563.74","8149.28","1 through 10","5454","8557.33","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","AETNA [1001]","HB CH AETNA HMO / PPO","440.75","58.3","","464.71","67.87","1012.10","221","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","440.75","58.3","","293.04","293.04","293.04","11","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","400.68","53","","983.89","983.89","983.89","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","438.48","58","","677.18","677.18","677.18","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","472.50","62.5","","46.58","46.58","46.58","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","551.88","73","","747.15","747.15","747.15","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.04","44.45","","1141.67","481.21","1141.67","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.04","44.45","","76.54","76.54","76.54","1 through 10","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.00","567.00","WELLPOINT [1015]","HB CH WELLPOINT","589.00","77.91","","273.64","94.28","1367.51","138","336.04","589","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.00","567.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","448.31","59.3","","720.78","230.14","2010.94","427","378","593.08","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.00","567.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","448.31","59.3","","344.45","344.45","344.45","1 through 10","378","593.08","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.00","567.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","593.08","78.45","","1120.13","1120.13","1120.13","1 through 10","378","593.08","percent of total billed charges",""
"SPINE PLATE ROI C AWL STARTER LONG","SUP-ITM-10165191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.00","567.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","593.08","78.45","","456.17","105.33","1284.66","242","378","593.08","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","464.71","67.87","1012.10","221","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","293.04","293.04","293.04","11","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","983.89","983.89","983.89","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","696.00","58","","677.18","677.18","677.18","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","750.00","62.5","","46.58","46.58","46.58","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","747.15","747.15","747.15","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","1141.67","481.21","1141.67","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","76.54","76.54","76.54","1 through 10","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","273.64","94.28","1367.51","138","533.4","934.92","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","720.78","230.14","2010.94","427","600","941.4","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","711.60","59.3","","344.45","344.45","344.45","1 through 10","600","941.4","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1120.13","1120.13","1120.13","1 through 10","600","941.4","percent of total billed charges",""
"SPINE PLATE STANDARD 5.5 TO 4.5X5 TO 7MM ROI C VERTEBRIDGE CERVICAL ANCHORING CAGE ANATOMIC BX/1EA","SUP-ITM-10103646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","456.17","105.33","1284.66","242","600","941.4","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","2190.90","412.50","9264.59","16","200.03","350.6","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","1903.20","1903.20","3826.66","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","2186.25","2186.25","2186.25","32","200.03","350.6","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","5556.60","5556.60","5556.60","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","1955.15","885.83","3150.40","26","200.03","350.6","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","831.03","253.22","2394.88","18","225","353.03","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","2481.69","1563.74","8149.28","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","122.10","91.57","AETNA [1001]","HB CH AETNA HMO / PPO","71.18","58.3","","2190.90","412.50","9264.59","16","54.27","95.13","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","70.82","58","","1903.20","1903.20","3826.66","1 through 10","54.27","95.13","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","76.31","62.5","","2186.25","2186.25","2186.25","32","54.27","95.13","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","122.10","91.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.13","73","","5556.60","5556.60","5556.60","1 through 10","54.27","95.13","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","122.10","91.57","WELLPOINT [1015]","HB CH WELLPOINT","95.13","77.91","","1955.15","885.83","3150.40","26","54.27","95.13","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.41","59.3","","831.03","253.22","2394.88","18","61.05","95.79","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.79","78.45","","2481.69","1563.74","8149.28","1 through 10","61.05","95.79","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","464.71","67.87","1012.10","221","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","293.04","293.04","293.04","11","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","983.89","983.89","983.89","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","677.18","677.18","677.18","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","46.58","46.58","46.58","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","747.15","747.15","747.15","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","1141.67","481.21","1141.67","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","76.54","76.54","76.54","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","273.64","94.28","1367.51","138","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","720.78","230.14","2010.94","427","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","266.85","59.3","","344.45","344.45","344.45","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1120.13","1120.13","1120.13","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","456.17","105.33","1284.66","242","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","464.71","67.87","1012.10","221","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","293.04","293.04","293.04","11","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","983.89","983.89","983.89","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","677.18","677.18","677.18","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","46.58","46.58","46.58","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","747.15","747.15","747.15","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","1141.67","481.21","1141.67","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","76.54","76.54","76.54","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","273.64","94.28","1367.51","138","200.03","350.6","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","720.78","230.14","2010.94","427","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","266.85","59.3","","344.45","344.45","344.45","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1120.13","1120.13","1120.13","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD 5.4X35.0MM SMOOTH PREBENT ROMEO PK/2EA","SUP-ITM-10102068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","456.17","105.33","1284.66","242","225","353.03","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","2190.90","412.50","9264.59","16","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","382.80","58","","1903.20","1903.20","3826.66","1 through 10","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","412.50","62.5","","2186.25","2186.25","2186.25","32","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","5556.60","5556.60","5556.60","1 through 10","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB CH WELLPOINT","514.21","77.91","","1955.15","885.83","3150.40","26","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","831.03","253.22","2394.88","18","330","517.77","percent of total billed charges",""
"SPINE ROD 5.5X35.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046229","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","2481.69","1563.74","8149.28","1 through 10","330","517.77","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","2190.90","412.50","9264.59","16","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","1903.20","1903.20","3826.66","1 through 10","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","2186.25","2186.25","2186.25","32","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","5556.60","5556.60","5556.60","1 through 10","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","1955.15","885.83","3150.40","26","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","831.03","253.22","2394.88","18","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","2481.69","1563.74","8149.28","1 through 10","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","2190.90","412.50","9264.59","16","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","348.00","58","","1903.20","1903.20","3826.66","1 through 10","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","375.00","62.5","","2186.25","2186.25","2186.25","32","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","5556.60","5556.60","5556.60","1 through 10","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","1955.15","885.83","3150.40","26","266.7","467.46","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","831.03","253.22","2394.88","18","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X500MM RELINE O TITANIUM STRAIGHT","SUP-ITM-10170577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","2481.69","1563.74","8149.28","1 through 10","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","2190.90","412.50","9264.59","16","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","382.80","58","","1903.20","1903.20","3826.66","1 through 10","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","412.50","62.5","","2186.25","2186.25","2186.25","32","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","5556.60","5556.60","5556.60","1 through 10","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB CH WELLPOINT","514.21","77.91","","1955.15","885.83","3150.40","26","293.37","514.21","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","831.03","253.22","2394.88","18","330","517.77","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","2481.69","1563.74","8149.28","1 through 10","330","517.77","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","2190.90","412.50","9264.59","16","200.03","350.6","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","1903.20","1903.20","3826.66","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","2186.25","2186.25","2186.25","32","200.03","350.6","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","5556.60","5556.60","5556.60","1 through 10","200.03","350.6","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","1955.15","885.83","3150.40","26","200.03","350.6","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","831.03","253.22","2394.88","18","225","353.03","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","2481.69","1563.74","8149.28","1 through 10","225","353.03","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","1530.90","1160.93","1884.08","89","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","5253.92","5253.92","5253.92","1 through 10","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","104.40","58","","12181.47","12181.47","12181.47","1 through 10","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","112.50","62.5","","1350.68","1350.68","1350.68","1 through 10","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","1910.74","891.94","1910.74","1 through 10","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","1829.79","1561.50","2617.12","88","80.01","140.24","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","1359.46","1201.30","1689.00","61","90","141.21","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","106.74","59.3","","1718.92","1718.92","1718.92","1 through 10","90","141.21","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","1910.74","1019.06","2344.84","74","90","141.21","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","AETNA [1001]","HB CH AETNA HMO / PPO","6762.80","58.3","","2190.90","412.50","9264.59","16","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6728.00","58","","1903.20","1903.20","3826.66","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7250.00","62.5","","2186.25","2186.25","2186.25","32","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8468.00","73","","5556.60","5556.60","5556.60","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","WELLPOINT [1015]","HB CH WELLPOINT","9037.56","77.91","","1955.15","885.83","3150.40","26","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6878.80","59.3","","831.03","253.22","2394.88","18","5800","9100.2","percent of total billed charges",""
"SPINE SABLE 10X26MM 6-12MM 8DEG","SUP-ITM-10321791","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9100.20","78.45","","2481.69","1563.74","8149.28","1 through 10","5800","9100.2","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","AETNA [1001]","HB CH AETNA HMO / PPO","6762.80","58.3","","2190.90","412.50","9264.59","16","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6728.00","58","","1903.20","1903.20","3826.66","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7250.00","62.5","","2186.25","2186.25","2186.25","32","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8468.00","73","","5556.60","5556.60","5556.60","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","WELLPOINT [1015]","HB CH WELLPOINT","9037.56","77.91","","1955.15","885.83","3150.40","26","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6878.80","59.3","","831.03","253.22","2394.88","18","5800","9100.2","percent of total billed charges",""
"SPINE SABLE 10X26MM 7-14MM 15DEG","SUP-ITM-10321793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9100.20","78.45","","2481.69","1563.74","8149.28","1 through 10","5800","9100.2","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","AETNA [1001]","HB CH AETNA HMO / PPO","6762.80","58.3","","2190.90","412.50","9264.59","16","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6728.00","58","","1903.20","1903.20","3826.66","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7250.00","62.5","","2186.25","2186.25","2186.25","32","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8468.00","73","","5556.60","5556.60","5556.60","1 through 10","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","both","","","11600.00","8700.00","WELLPOINT [1015]","HB CH WELLPOINT","9037.56","77.91","","1955.15","885.83","3150.40","26","5156.2","9037.56","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6878.80","59.3","","831.03","253.22","2394.88","18","5800","9100.2","percent of total billed charges",""
"SPINE SABLE 10X26MM 9-17MM 22DEG","SUP-ITM-10321795","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11600.00","8700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9100.20","78.45","","2481.69","1563.74","8149.28","1 through 10","5800","9100.2","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","2190.90","412.50","9264.59","16","2667","4674.6","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3480.00","58","","1903.20","1903.20","3826.66","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3750.00","62.5","","2186.25","2186.25","2186.25","32","2667","4674.6","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","5556.60","5556.60","5556.60","1 through 10","2667","4674.6","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","1955.15","885.83","3150.40","26","2667","4674.6","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","831.03","253.22","2394.88","18","3000","4707","percent of total billed charges",""
"SPINE SPACER 23X8MM LUMBAR ELEVATEXLOR POLYETHER ETHER KETONE","SUP-ITM-10177824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","2481.69","1563.74","8149.28","1 through 10","3000","4707","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","AETNA [1001]","HB CH AETNA HMO / PPO","1530.95","58.3","","2190.90","412.50","9264.59","16","1167.25","2045.91","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1523.07","58","","1903.20","1903.20","3826.66","1 through 10","1167.25","2045.91","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1641.24","62.5","","2186.25","2186.25","2186.25","32","1167.25","2045.91","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1916.97","73","","5556.60","5556.60","5556.60","1 through 10","1167.25","2045.91","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","WELLPOINT [1015]","HB CH WELLPOINT","2045.91","77.91","","1955.15","885.83","3150.40","26","1167.25","2045.91","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1557.21","59.3","","831.03","253.22","2394.88","18","1313","2060.09","percent of total billed charges",""
"SPINE SPACER 6MM ALLOGRAFT ARCH ODL ANGLED FREEZE DRIED","SUP-ITM-10048808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2060.09","78.45","","2481.69","1563.74","8149.28","1 through 10","1313","2060.09","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","2190.90","412.50","9264.59","16","1955.8","3428.04","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2552.00","58","","1903.20","1903.20","3826.66","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2750.00","62.5","","2186.25","2186.25","2186.25","32","1955.8","3428.04","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","5556.60","5556.60","5556.60","1 through 10","1955.8","3428.04","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","1955.15","885.83","3150.40","26","1955.8","3428.04","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","831.03","253.22","2394.88","18","2200","3451.8","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","2481.69","1563.74","8149.28","1 through 10","2200","3451.8","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","2190.90","412.50","9264.59","16","593.41","1040.1","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","774.30","58","","1903.20","1903.20","3826.66","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","834.38","62.5","","2186.25","2186.25","2186.25","32","593.41","1040.1","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","5556.60","5556.60","5556.60","1 through 10","593.41","1040.1","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","1955.15","885.83","3150.40","26","593.41","1040.1","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","831.03","253.22","2394.88","18","667.5","1047.31","percent of total billed charges",""
"SPIPNE CONNECTOR LARGE 30DEG SPINE POSTERIOR XIA II ROD TO","SUP-ITM-10026681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","2481.69","1563.74","8149.28","1 through 10","667.5","1047.31","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","842.00","631.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.41","1 through 10","351.32","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","29","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","318","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.81","28","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","338.21","363.89","38","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","802.00","601.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","475.59","59.3","","457.08","457.08","457.08","1 through 10","401","629.17","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","629.17","78.45","","599.66","355.37","599.66","12","401","629.17","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","AETNA [1001]","HB CH AETNA HMO / PPO","270.51","58.3","","255.72","255.72","255.72","1 through 10","176.52","528.85","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","MEDICARE [2001]","HB NWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","82","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.72","73","","230.01","230.01","230.01","1 through 10","176.52","528.85","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","167.75","182.49","1 through 10","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.25","44.45","","205.48","205.48","205.48","1 through 10","176.52","528.85","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.30","167.98","183.10","1 through 10","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","464.00","348.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.15","59.3","","264.29","264.29","264.29","11","224.5","364.01","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","464.00","348.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.01","78.45","","346.73","205.48","346.73","13","224.5","364.01","percent of total billed charges",""
"Splint of Lux/Avuls/Tooth","PX-76001989","CDM","41899","CPT","0510","RC","","","","outpatient","","","2013.00","1509.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1161.50","57.7","","6371.30","6371.30","6371.30","1 through 10","567.68","1579.2","percent of total billed charges",""
"Spontaneous Nystagmus Test","PX-47000068","CDM","92531","CPT","0920","RC","","","","both","","","533.00","399.75","AETNA [1001]","HB CH AETNA HMO / PPO","310.74","58.3","","293.71","293.71","293.71","1 through 10","282.49","415.26","percent of total billed charges",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","20223.35","15167.51","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","9090.85","","Case rate ($9,090.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,493.46, add-ons for qualifying new technology services are included. If operating cost exceeds $53,635.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,573.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,459.02. The transfer operating threshold is the transfer adjustment factor * $8,493.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.83. The transfer capital threshold is the transfer adjustment factor * $631.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7924.97","7924.97","7924.97","1 through 10","8102.62","9090.85","other","Inpatient DRG"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","20223.35","15167.51","MEDICARE [2001]","HB NWH MEDICARE","9090.85","","Case rate ($9,090.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,493.46, add-ons for qualifying new technology services are included. If operating cost exceeds $53,635.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,573.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,459.02. The transfer operating threshold is the transfer adjustment factor * $8,493.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.83. The transfer capital threshold is the transfer adjustment factor * $631.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8786.86","8771.10","8786.86","1 through 10","8102.62","9090.85","other","Inpatient DRG"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","20223.35","15167.51","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8102.62","","Case rate ($8,267.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,493.46, add-ons for qualifying new technology services are included. If operating cost exceeds $53,635.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,573.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,636.15. The transfer operating threshold is the transfer adjustment factor * $8,493.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.83. The transfer capital threshold is the transfer adjustment factor * $631.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7833.39","7833.39","7833.39","1 through 10","8102.62","9090.85","other","Inpatient DRG"
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","417.00","312.75","AETNA [1001]","HB CH AETNA HMO / PPO","243.11","58.3","","229.64","229.64","229.64","1 through 10","74.05","410.4","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","417.00","312.75","WELLPOINT [1015]","HB CH WELLPOINT","324.88","77.91","","318.98","318.98","318.98","1 through 10","74.05","410.4","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","256.28","256.28","256.28","1 through 10","97.28","441.75","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","291.00","218.25","AETNA [1001]","HB CH AETNA HMO / PPO","169.65","58.3","","160.46","160.46","160.46","1 through 10","90.27","410.4","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","90.27","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($92.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($69.07). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","92.12","90.37","92.12","1 through 10","90.27","410.4","fee schedule",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","692.00","519.00","AETNA [1001]","HB CH AETNA HMO / PPO","403.44","58.3","","381.59","357.58","381.59","175","81.36","657.4","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","692.00","519.00","TRICARE [160005]","HB NWH TRICARE","657.40","95","","83.01","83.01","84.24","25","81.36","657.4","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","81.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($83.02). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($63.85). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","82.36","81.36","82.36","27","81.36","657.4","fee schedule",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1530.90","1160.93","1884.08","89","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","5253.92","5253.92","5253.92","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2621.60","58","","12181.47","12181.47","12181.47","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2825.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2009.14","44.45","","1910.74","891.94","1910.74","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","1829.79","1561.50","2617.12","88","2009.14","3521.53","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1359.46","1201.30","1689.00","61","2260","3545.94","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1718.92","1718.92","1718.92","1 through 10","2260","3545.94","percent of total billed charges",""
"STABILIZER IMPLANT SIZE 4 KNEE FEMORAL COMPONENT TOTAL STABILIZED TRIATHLON RT 07","SUP-ITM-10030153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","1910.74","1019.06","2344.84","74","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1530.90","1160.93","1884.08","89","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","5253.92","5253.92","5253.92","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2621.60","58","","12181.47","12181.47","12181.47","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2825.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2009.14","44.45","","1910.74","891.94","1910.74","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","1829.79","1561.50","2617.12","88","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1359.46","1201.30","1689.00","61","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1718.92","1718.92","1718.92","1 through 10","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","1910.74","1019.06","2344.84","74","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1530.90","1160.93","1884.08","89","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","5253.92","5253.92","5253.92","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2621.60","58","","12181.47","12181.47","12181.47","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2825.00","62.5","","1350.68","1350.68","1350.68","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2009.14","44.45","","1910.74","891.94","1910.74","1 through 10","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","1829.79","1561.50","2617.12","88","2009.14","3521.53","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1359.46","1201.30","1689.00","61","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1718.92","1718.92","1718.92","1 through 10","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","1910.74","1019.06","2344.84","74","2260","3545.94","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","AETNA [1001]","HB CH AETNA HMO / PPO","4949.67","58.3","","2190.90","412.50","9264.59","16","3773.81","6614.56","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4924.20","58","","1903.20","1903.20","3826.66","1 through 10","3773.81","6614.56","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5306.25","62.5","","2186.25","2186.25","2186.25","32","3773.81","6614.56","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6197.70","73","","5556.60","5556.60","5556.60","1 through 10","3773.81","6614.56","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","WELLPOINT [1015]","HB CH WELLPOINT","6614.56","77.91","","1955.15","885.83","3150.40","26","3773.81","6614.56","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8490.00","6367.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5034.57","59.3","","831.03","253.22","2394.88","18","4245","6660.41","percent of total billed charges",""
"STAND LATERAL 12X18 50MM XL CAGE SPINE COROENT PEEK ALONE CERVICAL XLF","SUP-ITM-10057518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8490.00","6367.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6660.41","78.45","","2481.69","1563.74","8149.28","1 through 10","4245","6660.41","percent of total billed charges",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","outpatient","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","233.04","233.04","233.04","1 through 10","169.2","269.45","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","AETNA [1001]","HB CH AETNA HMO / PPO","1537.27","58.3","","464.71","67.87","1012.10","221","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1537.27","58.3","","293.04","293.04","293.04","11","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1397.51","53","","983.89","983.89","983.89","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1529.36","58","","677.18","677.18","677.18","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1648.01","62.5","","46.58","46.58","46.58","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1924.88","73","","747.15","747.15","747.15","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.07","44.45","","1141.67","481.21","1141.67","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.07","44.45","","76.54","76.54","76.54","1 through 10","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","both","","","2636.82","1977.61","WELLPOINT [1015]","HB CH WELLPOINT","2054.35","77.91","","273.64","94.28","1367.51","138","1172.07","2054.35","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2636.82","1977.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","1563.63","59.3","","720.78","230.14","2010.94","427","1318.41","2068.59","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2636.82","1977.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1563.63","59.3","","344.45","344.45","344.45","1 through 10","1318.41","2068.59","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2636.82","1977.61","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2068.59","78.45","","1120.13","1120.13","1120.13","1 through 10","1318.41","2068.59","percent of total billed charges",""
"STAPLE 11X13MM L13 XW COMPRESSION INTERAXIS UNI CLIP S/S IMPLANTABLE","SUP-ITM-10090130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2636.82","1977.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2068.59","78.45","","456.17","105.33","1284.66","242","1318.41","2068.59","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","AETNA [1001]","HB CH AETNA HMO / PPO","953.21","58.3","","464.71","67.87","1012.10","221","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","953.21","58.3","","293.04","293.04","293.04","11","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","866.55","53","","983.89","983.89","983.89","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","948.30","58","","677.18","677.18","677.18","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1021.88","62.5","","46.58","46.58","46.58","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1193.55","73","","747.15","747.15","747.15","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","726.76","44.45","","1141.67","481.21","1141.67","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","726.76","44.45","","76.54","76.54","76.54","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","WELLPOINT [1015]","HB CH WELLPOINT","1273.83","77.91","","273.64","94.28","1367.51","138","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","969.56","59.3","","720.78","230.14","2010.94","427","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","969.56","59.3","","344.45","344.45","344.45","1 through 10","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1282.66","78.45","","1120.13","1120.13","1120.13","1 through 10","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1282.66","78.45","","456.17","105.33","1284.66","242","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","AETNA [1001]","HB CH AETNA HMO / PPO","953.21","58.3","","464.71","67.87","1012.10","221","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","953.21","58.3","","293.04","293.04","293.04","11","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","866.55","53","","983.89","983.89","983.89","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","948.30","58","","677.18","677.18","677.18","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1021.88","62.5","","46.58","46.58","46.58","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1193.55","73","","747.15","747.15","747.15","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","726.76","44.45","","1141.67","481.21","1141.67","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","726.76","44.45","","76.54","76.54","76.54","1 through 10","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.00","1226.25","WELLPOINT [1015]","HB CH WELLPOINT","1273.83","77.91","","273.64","94.28","1367.51","138","726.76","1273.83","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","969.56","59.3","","720.78","230.14","2010.94","427","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","969.56","59.3","","344.45","344.45","344.45","1 through 10","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1282.66","78.45","","1120.13","1120.13","1120.13","1 through 10","817.5","1282.66","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.00","1226.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1282.66","78.45","","456.17","105.33","1284.66","242","817.5","1282.66","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","AETNA [1001]","HB CH AETNA HMO / PPO","1915.16","58.3","","464.71","67.87","1012.10","221","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1915.16","58.3","","293.04","293.04","293.04","11","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1741.05","53","","983.89","983.89","983.89","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1905.30","58","","677.18","677.18","677.18","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2053.13","62.5","","46.58","46.58","46.58","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","747.15","747.15","747.15","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.18","44.45","","1141.67","481.21","1141.67","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.18","44.45","","76.54","76.54","76.54","1 through 10","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","WELLPOINT [1015]","HB CH WELLPOINT","2559.34","77.91","","273.64","94.28","1367.51","138","1460.18","2559.34","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1948.01","59.3","","720.78","230.14","2010.94","427","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1948.01","59.3","","344.45","344.45","344.45","1 through 10","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","1120.13","1120.13","1120.13","1 through 10","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 11X15/12MM NITINOL","SUP-ITM-10212190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","456.17","105.33","1284.66","242","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","AETNA [1001]","HB CH AETNA HMO / PPO","2209.57","58.3","","464.71","67.87","1012.10","221","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2209.57","58.3","","293.04","293.04","293.04","11","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2008.70","53","","983.89","983.89","983.89","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2198.20","58","","677.18","677.18","677.18","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2368.75","62.5","","46.58","46.58","46.58","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2766.70","73","","747.15","747.15","747.15","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1684.66","44.45","","1141.67","481.21","1141.67","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1684.66","44.45","","76.54","76.54","76.54","1 through 10","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","WELLPOINT [1015]","HB CH WELLPOINT","2952.79","77.91","","273.64","94.28","1367.51","138","1684.66","2952.79","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2247.47","59.3","","720.78","230.14","2010.94","427","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2247.47","59.3","","344.45","344.45","344.45","1 through 10","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2973.26","78.45","","1120.13","1120.13","1120.13","1 through 10","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2973.26","78.45","","456.17","105.33","1284.66","242","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","464.71","67.87","1012.10","221","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","293.04","293.04","293.04","11","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","983.89","983.89","983.89","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.75","58","","677.18","677.18","677.18","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.94","62.5","","46.58","46.58","46.58","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","747.15","747.15","747.15","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","1141.67","481.21","1141.67","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","76.54","76.54","76.54","1 through 10","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","273.64","94.28","1367.51","138","1661.32","2911.89","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","720.78","230.14","2010.94","427","1868.75","2932.07","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.34","59.3","","344.45","344.45","344.45","1 through 10","1868.75","2932.07","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.75","2932.07","percent of total billed charges",""
"STAPLE DYNANITE 13X15/12MM NITINOL","SUP-ITM-10212194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","456.17","105.33","1284.66","242","1868.75","2932.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","AETNA [1001]","HB CH AETNA HMO / PPO","2675.97","58.3","","464.71","67.87","1012.10","221","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2675.97","58.3","","293.04","293.04","293.04","11","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2432.70","53","","983.89","983.89","983.89","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2662.20","58","","677.18","677.18","677.18","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2868.75","62.5","","46.58","46.58","46.58","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3350.70","73","","747.15","747.15","747.15","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2040.26","44.45","","1141.67","481.21","1141.67","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2040.26","44.45","","76.54","76.54","76.54","1 through 10","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","WELLPOINT [1015]","HB CH WELLPOINT","3576.07","77.91","","273.64","94.28","1367.51","138","2040.26","3576.07","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2721.87","59.3","","720.78","230.14","2010.94","427","2295","3600.86","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2721.87","59.3","","344.45","344.45","344.45","1 through 10","2295","3600.86","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3600.86","78.45","","1120.13","1120.13","1120.13","1 through 10","2295","3600.86","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3600.86","78.45","","456.17","105.33","1284.66","242","2295","3600.86","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","AETNA [1001]","HB CH AETNA HMO / PPO","1414.94","58.3","","464.71","67.87","1012.10","221","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1414.94","58.3","","293.04","293.04","293.04","11","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1286.31","53","","983.89","983.89","983.89","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1407.66","58","","677.18","677.18","677.18","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1516.88","62.5","","46.58","46.58","46.58","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1771.71","73","","747.15","747.15","747.15","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.80","44.45","","1141.67","481.21","1141.67","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.80","44.45","","76.54","76.54","76.54","1 through 10","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","WELLPOINT [1015]","HB CH WELLPOINT","1890.88","77.91","","273.64","94.28","1367.51","138","1078.8","1890.88","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1439.21","59.3","","720.78","230.14","2010.94","427","1213.5","1903.98","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1439.21","59.3","","344.45","344.45","344.45","1 through 10","1213.5","1903.98","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1903.98","78.45","","1120.13","1120.13","1120.13","1 through 10","1213.5","1903.98","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1903.98","78.45","","456.17","105.33","1284.66","242","1213.5","1903.98","percent of total billed charges",""
"Std Cogni Test per Hr by HC Pro","PX-90000043","CDM","96125","CPT","0918","RC","","","","outpatient","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","233.04","233.04","233.04","1 through 10","169.2","344","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","AETNA [1001]","HB CH AETNA HMO / PPO","7325.98","58.3","","1530.90","1160.93","1884.08","89","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6659.98","53","","5253.92","5253.92","5253.92","1 through 10","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","7288.28","58","","12181.47","12181.47","12181.47","1 through 10","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7853.75","62.5","","1350.68","1350.68","1350.68","1 through 10","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5585.59","44.45","","1910.74","891.94","1910.74","1 through 10","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","both","","","12566.00","9424.50","WELLPOINT [1015]","HB CH WELLPOINT","9790.17","77.91","","1829.79","1561.50","2617.12","88","5585.59","9790.17","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12566.00","9424.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7451.64","59.3","","1359.46","1201.30","1689.00","61","6283","9858.03","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12566.00","9424.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","7451.64","59.3","","1718.92","1718.92","1718.92","1 through 10","6283","9858.03","percent of total billed charges",""
"STEM HUMERAL 14X48MM ALTIVATE REVERSE STANDARD SHELL","SUP-ITM-10295439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12566.00","9424.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9858.03","78.45","","1910.74","1019.06","2344.84","74","6283","9858.03","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","AETNA [1001]","HB CH AETNA HMO / PPO","5693.05","58.3","","1530.90","1160.93","1884.08","89","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5175.50","53","","5253.92","5253.92","5253.92","1 through 10","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5663.76","58","","12181.47","12181.47","12181.47","1 through 10","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","6103.19","62.5","","1350.68","1350.68","1350.68","1 through 10","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4340.59","44.45","","1910.74","891.94","1910.74","1 through 10","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","both","","","9765.10","7323.82","WELLPOINT [1015]","HB CH WELLPOINT","7607.99","77.91","","1829.79","1561.50","2617.12","88","4340.59","7607.99","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","5790.70","59.3","","1359.46","1201.30","1689.00","61","4882.55","7660.72","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5790.70","59.3","","1718.92","1718.92","1718.92","1 through 10","4882.55","7660.72","percent of total billed charges",""
"STEM HUMERAL 6X108MM ALTIVATE REVERSE SMALL SHELL","SUP-ITM-10258507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9765.10","7323.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7660.72","78.45","","1910.74","1019.06","2344.84","74","4882.55","7660.72","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","247.11","185.33","AETNA [1001]","HB CH AETNA HMO / PPO","144.07","58.3","","1903.50","1903.50","1903.50","1 through 10","109.84","192.52","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","247.11","185.33","WELLPOINT [1015]","HB CH WELLPOINT","192.52","77.91","","194.63","194.63","194.63","1 through 10","109.84","192.52","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","247.11","185.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.54","59.3","","144.81","144.81","144.81","1 through 10","123.56","193.86","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139058","CDM","C1876","HCPCS","0278","RC","","","","both","","","165.90","124.42","AETNA [1001]","HB CH AETNA HMO / PPO","96.72","58.3","","1903.50","1903.50","1903.50","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139058","CDM","C1876","HCPCS","0278","RC","","","","both","","","165.90","124.42","WELLPOINT [1015]","HB CH WELLPOINT","129.25","77.91","","194.63","194.63","194.63","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139058","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","165.90","124.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","98.38","59.3","","144.81","144.81","144.81","1 through 10","82.95","130.15","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","both","","","403.50","302.62","WELLPOINT [1015]","HB CH WELLPOINT","314.37","77.91","","317.80","317.80","317.80","1 through 10","179.36","314.37","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","7551.15","7551.15","7551.15","1 through 10","2700","4236.3","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","165.90","124.42","AETNA [1001]","HB CH AETNA HMO / PPO","96.72","58.3","","188.13","151.57","188.13","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","165.90","124.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","87.93","53","","175.85","175.85","175.85","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","165.90","124.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.74","44.45","","255.09","255.09","255.09","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","165.90","124.42","WELLPOINT [1015]","HB CH WELLPOINT","129.25","77.91","","261.33","130.66","261.33","1 through 10","73.74","129.25","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","165.90","124.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","98.38","59.3","","194.43","189.79","327.42","11","82.95","130.15","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","165.90","124.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","130.15","78.45","","255.09","151.17","255.09","1 through 10","82.95","130.15","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","456.00","342.00","AETNA [1001]","HB CH AETNA HMO / PPO","265.85","58.3","","188.13","151.57","188.13","1 through 10","202.69","355.27","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.68","53","","175.85","175.85","175.85","1 through 10","202.69","355.27","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.69","44.45","","255.09","255.09","255.09","1 through 10","202.69","355.27","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB CH WELLPOINT","355.27","77.91","","261.33","130.66","261.33","1 through 10","202.69","355.27","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","270.41","59.3","","194.43","189.79","327.42","11","228","357.73","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.73","78.45","","255.09","151.17","255.09","1 through 10","228","357.73","percent of total billed charges",""
"STENT BILIARY 8.5FR 10X60MM WALLFLEX PLATINOL ALLOY PARTIAL PERMALUME COATED RAPID EXCHANGE","SUP-ITM-10073348","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3757.76","78.45","","7551.15","7551.15","7551.15","1 through 10","2395","3757.76","percent of total billed charges",""
"STENT BILIARY 8.5FR 80X10MM SILICONE PARTIALLY COVERED SELF EXP RAPID EXCHANGE WALLFLEX","SUP-ITM-10073349","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3757.76","78.45","","7551.15","7551.15","7551.15","1 through 10","2395","3757.76","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","7551.15","7551.15","7551.15","1 through 10","900","1412.1","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3639.92","2729.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2855.52","78.45","","7551.15","7551.15","7551.15","1 through 10","1819.96","2855.52","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3757.76","78.45","","7551.15","7551.15","7551.15","1 through 10","2395","3757.76","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","both","","","234.00","175.50","AETNA [1001]","HB CH AETNA HMO / PPO","136.42","58.3","","188.13","151.57","188.13","1 through 10","104.01","182.31","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","both","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","124.02","53","","175.85","175.85","175.85","1 through 10","104.01","182.31","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.01","44.45","","255.09","255.09","255.09","1 through 10","104.01","182.31","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB CH WELLPOINT","182.31","77.91","","261.33","130.66","261.33","1 through 10","104.01","182.31","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","234.00","175.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","138.76","59.3","","194.43","189.79","327.42","11","117","183.57","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 5CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000211","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","183.57","78.45","","255.09","151.17","255.09","1 through 10","117","183.57","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","7551.15","7551.15","7551.15","1 through 10","1777.5","2788.9","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4377.85","3283.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3434.42","78.45","","7551.15","7551.15","7551.15","1 through 10","2188.93","3434.42","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5954.85","4466.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4671.58","78.45","","7551.15","7551.15","7551.15","1 through 10","2977.43","4671.58","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6158.00","4618.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4830.95","78.45","","7551.15","7551.15","7551.15","1 through 10","3079","4830.95","percent of total billed charges",""
"STENT GRAFT 14FR 13X122MM ENDOVASCULAR ILIAC LEG ZENITH SPIRAL Z ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10094515","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7601.00","5700.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5962.98","78.45","","7551.15","7551.15","7551.15","1 through 10","3800.5","5962.98","percent of total billed charges",""
"STENT GRAFT 16MM 14 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114972","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6236.00","4677.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4892.14","78.45","","7551.15","7551.15","7551.15","1 through 10","3118","4892.14","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8856.00","6642.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6947.53","78.45","","7551.15","7551.15","7551.15","1 through 10","4428","6947.53","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10348.00","7761.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8118.01","78.45","","7551.15","7551.15","7551.15","1 through 10","5174","8118.01","percent of total billed charges",""
"STENT GRAFT 20FX32MM 14 102 AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10166570","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","20748.00","15561.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","16276.81","78.45","","7551.15","7551.15","7551.15","1 through 10","10374","16276.81","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21424.00","16068.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","16807.13","78.45","","7551.15","7551.15","7551.15","1 through 10","10712","16807.13","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8856.00","6642.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6947.53","78.45","","7551.15","7551.15","7551.15","1 through 10","4428","6947.53","percent of total billed charges",""
"STENT GRAFT 28MMX14.5 14CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135329","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21424.00","16068.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","16807.13","78.45","","7551.15","7551.15","7551.15","1 through 10","10712","16807.13","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8442.00","6331.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6622.75","78.45","","7551.15","7551.15","7551.15","1 through 10","4221","6622.75","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10443.38","7832.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8192.83","78.45","","7551.15","7551.15","7551.15","1 through 10","5221.69","8192.83","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","1903.50","1903.50","1903.50","1 through 10","1133.48","1986.71","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","194.63","194.63","194.63","1 through 10","1133.48","1986.71","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","144.81","144.81","144.81","1 through 10","1275","2000.48","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1903.50","1903.50","1903.50","1 through 10","733.43","1285.52","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","194.63","194.63","194.63","1 through 10","733.43","1285.52","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","144.81","144.81","144.81","1 through 10","825","1294.43","percent of total billed charges",""
"STENT LIFESTREAM 6MM 37MM 80CM .035IN VASCULAR EXPANDABLE BALLOON COVERED","SUP-ITM-10236602","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","7551.15","7551.15","7551.15","1 through 10","2700","4236.3","percent of total billed charges",""
"STENT SOLUS 10FR 5CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND","SUP-ITM-10028866","CDM","C2625","HCPCS","0278","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB CH WELLPOINT","355.27","77.91","","317.80","317.80","317.80","1 through 10","202.69","355.27","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","AETNA [1001]","HB CH AETNA HMO / PPO","352.09","58.3","","188.13","151.57","188.13","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","320.08","53","","175.85","175.85","175.85","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.45","44.45","","255.09","255.09","255.09","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","WELLPOINT [1015]","HB CH WELLPOINT","470.52","77.91","","261.33","130.66","261.33","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","358.13","59.3","","194.43","189.79","327.42","11","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 6.0FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065048","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","473.78","78.45","","255.09","151.17","255.09","1 through 10","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","both","","","571.26","428.44","AETNA [1001]","HB CH AETNA HMO / PPO","333.04","58.3","","188.13","151.57","188.13","1 through 10","253.93","445.07","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","both","","","571.26","428.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.77","53","","175.85","175.85","175.85","1 through 10","253.93","445.07","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","both","","","571.26","428.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.93","44.45","","255.09","255.09","255.09","1 through 10","253.93","445.07","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","both","","","571.26","428.44","WELLPOINT [1015]","HB CH WELLPOINT","445.07","77.91","","261.33","130.66","261.33","1 through 10","253.93","445.07","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","571.26","428.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.76","59.3","","194.43","189.79","327.42","11","285.63","448.15","percent of total billed charges",""
"STENT URETERAL 6FR 26CM POLARIS ULTRA PERCUFLEX HYDROPLUS COATED DUAL DUROMETER","SUP-ITM-10079935","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","571.26","428.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","448.15","78.45","","255.09","151.17","255.09","1 through 10","285.63","448.15","percent of total billed charges",""
"STENT URETERAL 6FRX22CM 0.038IN DOUBLE PIGTAIL LUBE SOFT GUIDEWIRE SUTURE C FLEX POSITIONER CATHETER","SUP-ITM-10014230","CDM","C2625","HCPCS","0278","RC","","","","both","","","577.65","433.24","WELLPOINT [1015]","HB CH WELLPOINT","450.05","77.91","","317.80","317.80","317.80","1 through 10","256.77","450.05","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","AETNA [1001]","HB CH AETNA HMO / PPO","352.09","58.3","","188.13","151.57","188.13","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","320.08","53","","175.85","175.85","175.85","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.45","44.45","","255.09","255.09","255.09","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","WELLPOINT [1015]","HB CH WELLPOINT","470.52","77.91","","261.33","130.66","261.33","1 through 10","268.45","470.52","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","358.13","59.3","","194.43","189.79","327.42","11","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 7FR 24CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072430","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","473.78","78.45","","255.09","151.17","255.09","1 through 10","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","AETNA [1001]","HB CH AETNA HMO / PPO","617.62","58.3","","188.13","151.57","188.13","1 through 10","470.9","825.37","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","561.48","53","","175.85","175.85","175.85","1 through 10","470.9","825.37","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.90","44.45","","255.09","255.09","255.09","1 through 10","470.9","825.37","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","WELLPOINT [1015]","HB CH WELLPOINT","825.37","77.91","","261.33","130.66","261.33","1 through 10","470.9","825.37","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","628.22","59.3","","194.43","189.79","327.42","11","529.7","831.09","percent of total billed charges",""
"STENT URETERAL 7FRX20CM FIRM TRIA","SUP-ITM-10273878","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.09","78.45","","255.09","151.17","255.09","1 through 10","529.7","831.09","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","AETNA [1001]","HB CH AETNA HMO / PPO","294.99","58.3","","188.13","151.57","188.13","1 through 10","224.91","394.21","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","268.17","53","","175.85","175.85","175.85","1 through 10","224.91","394.21","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.91","44.45","","255.09","255.09","255.09","1 through 10","224.91","394.21","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","WELLPOINT [1015]","HB CH WELLPOINT","394.21","77.91","","261.33","130.66","261.33","1 through 10","224.91","394.21","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","505.98","379.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","300.05","59.3","","194.43","189.79","327.42","11","252.99","396.94","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","505.98","379.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","396.94","78.45","","255.09","151.17","255.09","1 through 10","252.99","396.94","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 60MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050456","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3765.60","78.45","","7551.15","7551.15","7551.15","1 through 10","2400","3765.6","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 60MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10025872","CDM","C1876","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1903.50","1903.50","1903.50","1 through 10","1833.56","3213.79","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 60MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10025872","CDM","C1876","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","194.63","194.63","194.63","1 through 10","1833.56","3213.79","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 60MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10025872","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","144.81","144.81","144.81","1 through 10","2062.5","3236.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","7551.15","7551.15","7551.15","1 through 10","1995","3130.16","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159412","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","7551.15","7551.15","7551.15","1 through 10","1868.75","2932.07","percent of total billed charges",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","40375.60","30281.70","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","21176.37","","Case rate ($21,176.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,753.88, add-ons for qualifying new technology services are included. If operating cost exceeds $66,896.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,560.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $19,558.09. The transfer operating threshold is the transfer adjustment factor * $21,753.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.28. The transfer capital threshold is the transfer adjustment factor * $1,618.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20938.63","20938.63","20938.63","1 through 10","20752.84","25089.71","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","40375.60","30281.70","MEDICARE [2001]","HB NWH MEDICARE","21176.37","","Case rate ($21,176.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,753.88, add-ons for qualifying new technology services are included. If operating cost exceeds $66,896.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,560.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $19,558.09. The transfer operating threshold is the transfer adjustment factor * $21,753.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.28. The transfer capital threshold is the transfer adjustment factor * $1,618.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23174.20","23174.20","23215.86","1 through 10","20752.84","25089.71","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","40375.60","30281.70","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20752.84","","Case rate ($21,176.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $21,753.88, add-ons for qualifying new technology services are included. If operating cost exceeds $66,896.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,560.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $19,558.09. The transfer operating threshold is the transfer adjustment factor * $21,753.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.28. The transfer capital threshold is the transfer adjustment factor * $1,618.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20719.02","20711.12","20720.65","1 through 10","20752.84","25089.71","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","67838.69","50879.02","MEDICARE [2001]","HB NWH MEDICARE","43210.46","","Case rate ($43,210.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $44,388.88, add-ons for qualifying new technology services are included. If operating cost exceeds $89,531.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,244.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $39,908.37. The transfer operating threshold is the transfer adjustment factor * $44,388.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,302.10. The transfer capital threshold is the transfer adjustment factor * $3,302.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48474.84","48474.84","48474.84","1 through 10","42346.25","50226.231","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","67838.69","50879.02","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","42346.25","","Case rate ($43,210.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $44,388.88, add-ons for qualifying new technology services are included. If operating cost exceeds $89,531.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,244.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $39,908.37. The transfer operating threshold is the transfer adjustment factor * $44,388.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,302.10. The transfer capital threshold is the transfer adjustment factor * $3,302.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","48840.39","48840.39","48840.39","1 through 10","42346.25","50226.231","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","32086.77","24065.08","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","14298.68","","Case rate ($13,882.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,260.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,403.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,002.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,821.34. The transfer operating threshold is the transfer adjustment factor * $14,260.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.86. The transfer capital threshold is the transfer adjustment factor * $1,060.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14309.22","14309.22","14309.22","1 through 10","13604.57","15758.1215","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","32086.77","24065.08","MEDICARE [2001]","HB NWH MEDICARE","13882.21","","Case rate ($13,882.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,260.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,403.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,002.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,821.34. The transfer operating threshold is the transfer adjustment factor * $14,260.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.86. The transfer capital threshold is the transfer adjustment factor * $1,060.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15235.98","14484.70","15235.98","1 through 10","13604.57","15758.1215","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","32086.77","24065.08","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","13604.57","","Case rate ($13,882.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,260.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,403.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,002.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,821.34. The transfer operating threshold is the transfer adjustment factor * $14,260.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.86. The transfer capital threshold is the transfer adjustment factor * $1,060.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13590.48","13590.48","13590.48","1 through 10","13604.57","15758.1215","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","32086.77","24065.08","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13604.57","","Case rate ($13,882.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $14,260.80, add-ons for qualifying new technology services are included. If operating cost exceeds $59,403.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,002.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,821.34. The transfer operating threshold is the transfer adjustment factor * $14,260.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.86. The transfer capital threshold is the transfer adjustment factor * $1,060.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13586.99","13586.99","13594.90","1 through 10","13604.57","15758.1215","other","Inpatient DRG"
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","1 through 10","14.69","169.1","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","202.76","1 through 10","15.46","139.64","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","133.00","133.00","1 through 10","15.46","139.64","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","AETNA [1001]","HB CH AETNA HMO / PPO","543.36","58.3","","513.70","513.70","1027.40","1 through 10","351.32","981.49","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","18","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","198","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","680.36","73","","906.00","517.72","906.00","1 through 10","351.32","981.49","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","TRICARE [160005]","HB NWH TRICARE","351.32","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","351.32","351.32","351.32","1 through 10","351.32","981.49","other","Tricare OPPS"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.41","362.81","27","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.27","44.45","","696.53","696.53","696.53","1 through 10","351.32","981.49","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","336.72","363.42","19","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.27","44.45","","412.77","412.77","412.77","1 through 10","351.32","981.49","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","932.00","699.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","552.68","59.3","","530.92","530.92","530.92","69","416.64","993.25","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.15","78.45","","696.53","412.77","906.00","60","416.64","993.25","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","19","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","74.26","72.1","","99.50","99.50","99.50","1 through 10","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","59.74","58","","59.40","59.40","59.40","1 through 10","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","62.73","60.9","","59.40","59.40","59.40","1 through 10","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","64.38","62.5","","64.00","64.00","64.00","1 through 10","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","WELLPOINT [1015]","HB CH WELLPOINT","80.25","77.91","","78.76","78.76","78.76","1 through 10","54.59","97.95","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","49.81","58.60","1 through 10","33.17","80.8","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","62.32","60.5","","66.30","66.30","66.30","1 through 10","33.17","80.8","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","45.56","76.88","1 through 10","33.17","80.8","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","36.29","36.29","36.29","1 through 10","5.39","62.7","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","112.50","37.50","112.50","1 through 10","5.67","51.78","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","49.20","49.20","49.20","1 through 10","5.67","51.78","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","2914.41","2185.81","AETNA [1001]","HB CH AETNA HMO / PPO","1699.10","58.3","","1952.48","1215.31","1952.48","1 through 10","1295.46","2270.62","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","2914.41","2185.81","WELLPOINT [1015]","HB CH WELLPOINT","2270.62","77.91","","2735.63","2146.75","4736.42","1 through 10","1295.46","2270.62","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2914.41","2185.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.25","59.3","","1597.25","1552.67","1756.87","1 through 10","1457.21","2286.35","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2914.41","2185.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2286.35","78.45","","2647.39","1568.87","3176.87","1 through 10","1457.21","2286.35","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","3384.99","3384.99","3384.99","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","10495.26","3498.42","10495.26","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,919). Procedure 2, Per diem ($1,459.50). Procedures 3 - 9999, Per diem ($729.50).","2919.00","2919.00","2919.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","3218.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","TRICARE [160005]","HB NWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","10566.00","3775.88","10566.00","1 through 10","1984.13","3888.77","other","Tricare OPPS"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","WELLPOINT [1015]","HB CH WELLPOINT","3603.34","77.91","","10671.97","10671.97","10671.97","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","1 through 10","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3823.55","3823.55","3904.56","17","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","15747.30","15747.30","15747.30","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","9889.84","4589.74","9889.84","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","3384.99","3384.99","6769.98","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5291.60","6247.91","1 through 10","1984.13","3888.77","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,919). Procedure 2, Per diem ($1,459.50). Procedures 3 - 9999, Per diem ($729.50).","2481.15","2481.15","2481.15","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,919). Procedure 2, Per diem ($1,459.50). Procedures 3 - 9999, Per diem ($729.50).","2919.00","2919.00","2919.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","9654.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","12","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3899.16","3823.55","3904.56","36","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","3498.42","3498.42","3498.42","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9605.64","4994.08","9605.64","13","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5249.10","5249.10","5249.10","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","4589.74","4589.74","4705.82","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8481.00","6360.75","AETNA [1001]","HB CH AETNA HMO / PPO","4944.42","58.3","","2343.98","2343.98","2343.98","1 through 10","2125.14","6607.55","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8481.00","6360.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","6607.55","other","Multiple Surgery"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8481.00","6360.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,919). Procedure 2, Per diem ($1,459.50). Procedures 3 - 9999, Per diem ($729.50).","2919.00","2919.00","2919.00","1 through 10","2125.14","6607.55","per diem",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8481.00","6360.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","3218.00","1 through 10","2125.14","6607.55","per diem",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8481.00","6360.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3899.16","3899.16","1 through 10","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8481.00","6360.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9605.64","4994.08","14982.24","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8481.00","6360.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5057.83","5057.83","5057.83","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8481.00","6360.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6653.34","78.45","","2719.93","2719.93","2719.93","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1258.00","943.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.03","386.03","386.03","1 through 10","405.83","1085.77","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1258.00","943.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","384.46","384.46","384.46","1 through 10","405.83","1085.77","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","384.47","384.47","384.47","1 through 10","405.83","1085.77","other","OPPS APC"
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","AETNA [1001]","HB CH AETNA HMO / PPO","3742.28","58.3","","2343.98","1692.50","2343.98","1 through 10","2753.75","5001.04","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2753.75","5001.04","per diem",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3149.80","49.07","","3855.09","3775.00","3855.09","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3215.92","50.1","","3860.43","3780.34","3860.43","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3806.47","59.3","","3416.38","2422.52","3416.38","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.81","1 through 10","4.66","40.85","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.73","78.45","","32.29","32.29","32.29","1 through 10","4.89","33.73","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","36.29","36.29","36.29","1 through 10","7.33","62.7","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","143","8.48","78.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","83.00","62.25","TRICARE [160005]","HB NWH TRICARE","78.85","95","","10.42","9.90","10.42","1 through 10","8.48","78.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","44.45","","62.27","36.90","62.27","1 through 10","8.48","78.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","130","8.92","65.11","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","62.27","62.27","62.27","1 through 10","8.92","65.11","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","62.27","36.90","62.27","151","8.92","65.11","percent of total billed charges",""
"Suture Tendon Infrapatellar Pri","PX-76000571","CDM","27380","CPT","0761","RC","","","","both","","","8660.00","6495.00","WELLPOINT [1015]","HB CH WELLPOINT","6747.01","77.91","","8685.65","8685.65","8685.65","1 through 10","3715.14","9357.58","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","AETNA [1001]","HB CH AETNA HMO / PPO","72.86","58.3","","464.71","67.87","1012.10","221","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","72.86","58.3","","293.04","293.04","293.04","11","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.24","53","","983.89","983.89","983.89","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","72.49","58","","677.18","677.18","677.18","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","78.11","62.5","","46.58","46.58","46.58","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.24","73","","747.15","747.15","747.15","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.55","44.45","","1141.67","481.21","1141.67","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.55","44.45","","76.54","76.54","76.54","1 through 10","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","WELLPOINT [1015]","HB CH WELLPOINT","97.37","77.91","","273.64","94.28","1367.51","138","55.55","97.37","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.11","59.3","","720.78","230.14","2010.94","427","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","74.11","59.3","","344.45","344.45","344.45","1 through 10","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","98.05","78.45","","1120.13","1120.13","1120.13","1 through 10","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.05","78.45","","456.17","105.33","1284.66","242","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","464.71","67.87","1012.10","221","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","293.04","293.04","293.04","11","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","983.89","983.89","983.89","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","69.60","58","","677.18","677.18","677.18","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","75.00","62.5","","46.58","46.58","46.58","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","747.15","747.15","747.15","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","1141.67","481.21","1141.67","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","76.54","76.54","76.54","1 through 10","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","273.64","94.28","1367.51","138","53.34","93.49","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","720.78","230.14","2010.94","427","60","94.14","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","71.16","59.3","","344.45","344.45","344.45","1 through 10","60","94.14","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","1120.13","1120.13","1120.13","1 through 10","60","94.14","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","456.17","105.33","1284.66","242","60","94.14","percent of total billed charges",""
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7778.02","","Case rate ($7,551.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,974.40. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7800.60","7800.60","7800.60","1 through 10","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","8303.04","","Case rate ($8,303.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,725.96. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7515.88","7515.88","7515.88","1 through 10","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","GENERIC MEDICARE REPLACEMENT [1010]","HB NWH MEDICARE","8303.04","","Case rate ($8,303.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,725.96. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7470.24","7470.24","7470.24","1 through 10","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","MEDICARE [2001]","HB NWH MEDICARE","8303.04","","Case rate ($8,303.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,725.96. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8315.83","8315.72","8330.78","73","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7400.45","","Case rate ($7,551.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,974.40. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7429.15","7426.90","32270.50","1 through 10","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","25379.39","19034.54","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7400.45","","Case rate ($7,551.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,757.42, add-ons for qualifying new technology services are included. If operating cost exceeds $52,899.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,519.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,974.40. The transfer operating threshold is the transfer adjustment factor * $7,757.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.08. The transfer capital threshold is the transfer adjustment factor * $577.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7426.89","7426.89","7426.89","1 through 10","7400.45","8946.97","other","Inpatient DRG"
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61654.15","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8518.3578","","Fee schedule rate ($16,671.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8518.3578","16028.90","16028.90","1 through 10","3836.07","27507.36","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61654.15","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19709.33","","Fee schedule rate ($19,709.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19135.45","19135.45","19135.45","1 through 10","3836.07","27507.36","case rate",""
"Syncope And Collapse,MINOR","204","DRG","","","","","","","","inpatient","","","22766.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14159.79","","Standard inlier is a Case rate ($14,159.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,170, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,009.92) for the length of stay and the standard reimbursement.","13516.16","13516.16","13516.16","1 through 10","3836.07","27507.36","case rate",""
"Syncope And Collapse,MINOR","204","DRG","","","","","","","","inpatient","","","22766.94","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","3836.07","","Case rate ($4,132.75). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $46,562.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4143.38","4143.38","4143.38","1 through 10","3836.07","27507.36","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","20432.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15495.93","","Standard inlier is a Case rate ($15,495.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $27,546, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,199.71) for the length of stay and the standard reimbursement.","14791.77","14791.77","14791.77","1 through 10","3836.07","27507.36","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","20432.67","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8518.3578","","Fee schedule rate ($11,078.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8518.3578","11078.36","11078.36","1 through 10","3836.07","27507.36","case rate",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","both","","","37.00","27.75","AETNA [1001]","HB CH AETNA HMO / PPO","21.57","58.3","","20.41","20.41","20.41","1 through 10","4.18","35.15","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","37.00","27.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.94","59.3","","21.10","21.10","21.10","1 through 10","4.4","29.03","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","16.40","27.68","1 through 10","4.4","29.03","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","24.95","24.95","24.95","1 through 10","4.31","42.75","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","6796.00","5097.00","AETNA [1001]","HB CH AETNA HMO / PPO","3962.07","58.3","","2190.90","412.50","9264.59","16","3020.82","5294.76","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","6796.00","5097.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3941.68","58","","1903.20","1903.20","3826.66","1 through 10","3020.82","5294.76","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","6796.00","5097.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4247.50","62.5","","2186.25","2186.25","2186.25","32","3020.82","5294.76","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","6796.00","5097.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4961.08","73","","5556.60","5556.60","5556.60","1 through 10","3020.82","5294.76","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","6796.00","5097.00","WELLPOINT [1015]","HB CH WELLPOINT","5294.76","77.91","","1955.15","885.83","3150.40","26","3020.82","5294.76","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6796.00","5097.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4030.03","59.3","","831.03","253.22","2394.88","18","3398","5331.46","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6796.00","5097.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5331.46","78.45","","2481.69","1563.74","8149.28","1 through 10","3398","5331.46","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","AETNA [1001]","HB CH AETNA HMO / PPO","4065.84","58.3","","2190.90","412.50","9264.59","16","3099.94","5433.44","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4044.92","58","","1903.20","1903.20","3826.66","1 through 10","3099.94","5433.44","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4358.75","62.5","","2186.25","2186.25","2186.25","32","3099.94","5433.44","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5091.02","73","","5556.60","5556.60","5556.60","1 through 10","3099.94","5433.44","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","WELLPOINT [1015]","HB CH WELLPOINT","5433.44","77.91","","1955.15","885.83","3150.40","26","3099.94","5433.44","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6974.00","5230.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4135.58","59.3","","831.03","253.22","2394.88","18","3487","5471.1","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 15/2 EXPRESS II OI","SUP-ITM-10209319","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5471.10","78.45","","2481.69","1563.74","8149.28","1 through 10","3487","5471.1","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","AETNA [1001]","HB CH AETNA HMO / PPO","2549.60","58.3","","464.71","67.87","1012.10","221","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2549.60","58.3","","293.04","293.04","293.04","11","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2317.82","53","","983.89","983.89","983.89","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2536.49","58","","677.18","677.18","677.18","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2733.28","62.5","","46.58","46.58","46.58","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3192.47","73","","747.15","747.15","747.15","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.91","44.45","","1141.67","481.21","1141.67","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.91","44.45","","76.54","76.54","76.54","1 through 10","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.25","3279.94","WELLPOINT [1015]","HB CH WELLPOINT","3407.20","77.91","","273.64","94.28","1367.51","138","1943.91","3407.2","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.25","3279.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2593.34","59.3","","720.78","230.14","2010.94","427","2186.63","3430.81","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.25","3279.94","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2593.34","59.3","","344.45","344.45","344.45","1 through 10","2186.63","3430.81","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.25","3279.94","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3430.81","78.45","","1120.13","1120.13","1120.13","1 through 10","2186.63","3430.81","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.25","3279.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3430.81","78.45","","456.17","105.33","1284.66","242","2186.63","3430.81","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","WELLPOINT [1015]","HB CH WELLPOINT","2711.27","77.91","","317.80","317.80","317.80","1 through 10","1546.86","2711.27","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","AETNA [1001]","HB CH AETNA HMO / PPO","811.54","58.3","","464.71","67.87","1012.10","221","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","811.54","58.3","","293.04","293.04","293.04","11","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","737.76","53","","983.89","983.89","983.89","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","807.36","58","","677.18","677.18","677.18","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","870.00","62.5","","46.58","46.58","46.58","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1016.16","73","","747.15","747.15","747.15","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.74","44.45","","1141.67","481.21","1141.67","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.74","44.45","","76.54","76.54","76.54","1 through 10","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","both","","","1392.00","1044.00","WELLPOINT [1015]","HB CH WELLPOINT","1084.51","77.91","","273.64","94.28","1367.51","138","618.74","1084.51","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1392.00","1044.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","825.46","59.3","","720.78","230.14","2010.94","427","696","1092.02","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1392.00","1044.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","825.46","59.3","","344.45","344.45","344.45","1 through 10","696","1092.02","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1392.00","1044.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1092.02","78.45","","1120.13","1120.13","1120.13","1 through 10","696","1092.02","percent of total billed charges",""
"SYSTEM DELIVERY STRAIGHT NEEDLE ULTRA FAST FIX STRAIGHT AB","SUP-ITM-10036451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1392.00","1044.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1092.02","78.45","","456.17","105.33","1284.66","242","696","1092.02","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.33","1691.50","AETNA [1001]","HB CH AETNA HMO / PPO","1314.86","58.3","","2190.90","412.50","9264.59","16","1002.49","1757.13","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.33","1691.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1308.09","58","","1903.20","1903.20","3826.66","1 through 10","1002.49","1757.13","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.33","1691.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1409.58","62.5","","2186.25","2186.25","2186.25","32","1002.49","1757.13","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.33","1691.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1646.39","73","","5556.60","5556.60","5556.60","1 through 10","1002.49","1757.13","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.33","1691.50","WELLPOINT [1015]","HB CH WELLPOINT","1757.13","77.91","","1955.15","885.83","3150.40","26","1002.49","1757.13","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.33","1691.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1337.41","59.3","","831.03","253.22","2394.88","18","1127.67","1769.31","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.33","1691.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1769.31","78.45","","2481.69","1563.74","8149.28","1 through 10","1127.67","1769.31","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","7478.00","5608.50","AETNA [1001]","HB CH AETNA HMO / PPO","4359.67","58.3","","1903.50","1903.50","1903.50","1 through 10","3323.97","5826.11","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","7478.00","5608.50","WELLPOINT [1015]","HB CH WELLPOINT","5826.11","77.91","","194.63","194.63","194.63","1 through 10","3323.97","5826.11","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7478.00","5608.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4434.45","59.3","","144.81","144.81","144.81","1 through 10","3739","5866.49","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","AETNA [1001]","HB CH AETNA HMO / PPO","2587.06","58.3","","464.71","67.87","1012.10","221","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2587.06","58.3","","293.04","293.04","293.04","11","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2351.88","53","","983.89","983.89","983.89","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2573.75","58","","677.18","677.18","677.18","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2773.44","62.5","","46.58","46.58","46.58","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","747.15","747.15","747.15","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1972.47","44.45","","1141.67","481.21","1141.67","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1972.47","44.45","","76.54","76.54","76.54","1 through 10","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","WELLPOINT [1015]","HB CH WELLPOINT","3457.26","77.91","","273.64","94.28","1367.51","138","1972.47","3457.26","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2631.44","59.3","","720.78","230.14","2010.94","427","2218.75","3481.22","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2631.44","59.3","","344.45","344.45","344.45","1 through 10","2218.75","3481.22","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3481.22","78.45","","1120.13","1120.13","1120.13","1 through 10","2218.75","3481.22","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3481.22","78.45","","456.17","105.33","1284.66","242","2218.75","3481.22","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","464.71","67.87","1012.10","221","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","293.04","293.04","293.04","11","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","983.89","983.89","983.89","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2512.13","58","","677.18","677.18","677.18","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2707.03","62.5","","46.58","46.58","46.58","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","747.15","747.15","747.15","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","1141.67","481.21","1141.67","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.24","44.45","","76.54","76.54","76.54","1 through 10","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","273.64","94.28","1367.51","138","1925.24","3374.48","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","720.78","230.14","2010.94","427","2165.63","3397.87","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2568.43","59.3","","344.45","344.45","344.45","1 through 10","2165.63","3397.87","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","1120.13","1120.13","1120.13","1 through 10","2165.63","3397.87","percent of total billed charges",""
"SYSTEM FIXATION 2.4X30MM NAIL TRIMMABLE TWO IMPLANT","SUP-ITM-10304318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","456.17","105.33","1284.66","242","2165.63","3397.87","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","AETNA [1001]","HB CH AETNA HMO / PPO","2160.45","58.3","","464.71","67.87","1012.10","221","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2160.45","58.3","","293.04","293.04","293.04","11","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1964.05","53","","983.89","983.89","983.89","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2149.34","58","","677.18","677.18","677.18","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2316.09","62.5","","46.58","46.58","46.58","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2705.20","73","","747.15","747.15","747.15","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1647.21","44.45","","1141.67","481.21","1141.67","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1647.21","44.45","","76.54","76.54","76.54","1 through 10","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.75","2779.31","WELLPOINT [1015]","HB CH WELLPOINT","2887.15","77.91","","273.64","94.28","1367.51","138","1647.21","2887.15","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.75","2779.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2197.51","59.3","","720.78","230.14","2010.94","427","1852.88","2907.16","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.75","2779.31","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2197.51","59.3","","344.45","344.45","344.45","1 through 10","1852.88","2907.16","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.75","2779.31","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2907.16","78.45","","1120.13","1120.13","1120.13","1 through 10","1852.88","2907.16","percent of total billed charges",""
"SYSTEM FIXATION 2.5X16MM 10DEG ANGLED IMPLANT INSTRUMENT KIT HAMMERTOE","SUP-ITM-10304313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.75","2779.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2907.16","78.45","","456.17","105.33","1284.66","242","1852.88","2907.16","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","464.71","67.87","1012.10","221","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","293.04","293.04","293.04","11","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","983.89","983.89","983.89","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","443.70","58","","677.18","677.18","677.18","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","478.13","62.5","","46.58","46.58","46.58","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","747.15","747.15","747.15","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","1141.67","481.21","1141.67","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","76.54","76.54","76.54","1 through 10","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","273.64","94.28","1367.51","138","340.04","596.01","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","720.78","230.14","2010.94","427","382.5","600.14","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","453.65","59.3","","344.45","344.45","344.45","1 through 10","382.5","600.14","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","1120.13","1120.13","1120.13","1 through 10","382.5","600.14","percent of total billed charges",""
"SYSTEM FIXATION RIGIDLOOP CORTICAL STANDARD","SUP-ITM-10148876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","456.17","105.33","1284.66","242","382.5","600.14","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","AETNA [1001]","HB CH AETNA HMO / PPO","2264.96","58.3","","464.71","67.87","1012.10","221","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2264.96","58.3","","293.04","293.04","293.04","11","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2059.05","53","","983.89","983.89","983.89","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2253.30","58","","677.18","677.18","677.18","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2428.13","62.5","","46.58","46.58","46.58","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2836.05","73","","747.15","747.15","747.15","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.88","44.45","","1141.67","481.21","1141.67","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.88","44.45","","76.54","76.54","76.54","1 through 10","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3885.00","2913.75","WELLPOINT [1015]","HB CH WELLPOINT","3026.80","77.91","","273.64","94.28","1367.51","138","1726.88","3026.8","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3885.00","2913.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.81","59.3","","720.78","230.14","2010.94","427","1942.5","3047.78","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3885.00","2913.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2303.81","59.3","","344.45","344.45","344.45","1 through 10","1942.5","3047.78","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3885.00","2913.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3047.78","78.45","","1120.13","1120.13","1120.13","1 through 10","1942.5","3047.78","percent of total billed charges",""
"SYSTEM IMPLANT 2 INCISION DISTAL BICEPS","SUP-ITM-10294389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3885.00","2913.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.78","78.45","","456.17","105.33","1284.66","242","1942.5","3047.78","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","464.71","67.87","1012.10","221","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","293.04","293.04","293.04","11","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","983.89","983.89","983.89","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2167.75","58","","677.18","677.18","677.18","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2335.94","62.5","","46.58","46.58","46.58","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","747.15","747.15","747.15","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","1141.67","481.21","1141.67","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","76.54","76.54","76.54","1 through 10","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","273.64","94.28","1367.51","138","1661.32","2911.89","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","720.78","230.14","2010.94","427","1868.75","2932.07","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2216.34","59.3","","344.45","344.45","344.45","1 through 10","1868.75","2932.07","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","1120.13","1120.13","1120.13","1 through 10","1868.75","2932.07","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","456.17","105.33","1284.66","242","1868.75","2932.07","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","AETNA [1001]","HB CH AETNA HMO / PPO","2536.05","58.3","","464.71","67.87","1012.10","221","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2536.05","58.3","","293.04","293.04","293.04","11","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2305.50","53","","983.89","983.89","983.89","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2523.00","58","","677.18","677.18","677.18","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2718.75","62.5","","46.58","46.58","46.58","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3175.50","73","","747.15","747.15","747.15","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","1141.67","481.21","1141.67","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","76.54","76.54","76.54","1 through 10","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB CH WELLPOINT","3389.09","77.91","","273.64","94.28","1367.51","138","1933.58","3389.09","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2579.55","59.3","","720.78","230.14","2010.94","427","2175","3412.58","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2579.55","59.3","","344.45","344.45","344.45","1 through 10","2175","3412.58","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","1120.13","1120.13","1120.13","1 through 10","2175","3412.58","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","456.17","105.33","1284.66","242","2175","3412.58","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","AETNA [1001]","HB CH AETNA HMO / PPO","2033.21","58.3","","1530.90","1160.93","1884.08","89","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1848.38","53","","5253.92","5253.92","5253.92","1 through 10","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2022.75","58","","12181.47","12181.47","12181.47","1 through 10","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2179.69","62.5","","1350.68","1350.68","1350.68","1 through 10","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1550.19","44.45","","1910.74","891.94","1910.74","1 through 10","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","WELLPOINT [1015]","HB CH WELLPOINT","2717.11","77.91","","1829.79","1561.50","2617.12","88","1550.19","2717.11","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3487.50","2615.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2068.09","59.3","","1359.46","1201.30","1689.00","61","1743.75","2735.94","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3487.50","2615.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2068.09","59.3","","1718.92","1718.92","1718.92","1 through 10","1743.75","2735.94","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE FOREFOOT PEEK","SUP-ITM-10237346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3487.50","2615.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2735.94","78.45","","1910.74","1019.06","2344.84","74","1743.75","2735.94","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","AETNA [1001]","HB CH AETNA HMO / PPO","650.33","58.3","","464.71","67.87","1012.10","221","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","650.33","58.3","","293.04","293.04","293.04","11","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","591.21","53","","983.89","983.89","983.89","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","646.98","58","","677.18","677.18","677.18","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","697.18","62.5","","46.58","46.58","46.58","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","814.31","73","","747.15","747.15","747.15","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.84","44.45","","1141.67","481.21","1141.67","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.84","44.45","","76.54","76.54","76.54","1 through 10","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","both","","","1115.49","836.62","WELLPOINT [1015]","HB CH WELLPOINT","869.08","77.91","","273.64","94.28","1367.51","138","495.84","869.08","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1115.49","836.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","661.49","59.3","","720.78","230.14","2010.94","427","557.75","875.1","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1115.49","836.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","661.49","59.3","","344.45","344.45","344.45","1 through 10","557.75","875.1","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1115.49","836.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","875.10","78.45","","1120.13","1120.13","1120.13","1 through 10","557.75","875.1","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST FIX ASSEMBLY STRAIGHT","SUP-ITM-10049717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1115.49","836.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","875.10","78.45","","456.17","105.33","1284.66","242","557.75","875.1","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","464.71","67.87","1012.10","221","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","293.04","293.04","293.04","11","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","983.89","983.89","983.89","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1174.50","58","","677.18","677.18","677.18","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1265.63","62.5","","46.58","46.58","46.58","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","747.15","747.15","747.15","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","1141.67","481.21","1141.67","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","76.54","76.54","76.54","1 through 10","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","273.64","94.28","1367.51","138","900.11","1577.68","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","720.78","230.14","2010.94","427","1012.5","1588.61","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1200.83","59.3","","344.45","344.45","344.45","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1012.5","1588.61","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","456.17","105.33","1284.66","242","1012.5","1588.61","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","464.71","67.87","1012.10","221","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","293.04","293.04","293.04","11","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","983.89","983.89","983.89","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","826.50","58","","677.18","677.18","677.18","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","890.63","62.5","","46.58","46.58","46.58","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","747.15","747.15","747.15","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","1141.67","481.21","1141.67","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","76.54","76.54","76.54","1 through 10","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","273.64","94.28","1367.51","138","633.41","1110.22","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","720.78","230.14","2010.94","427","712.5","1117.91","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","845.03","59.3","","344.45","344.45","344.45","1 through 10","712.5","1117.91","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","1120.13","1120.13","1120.13","1 through 10","712.5","1117.91","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","456.17","105.33","1284.66","242","712.5","1117.91","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","AETNA [1001]","HB CH AETNA HMO / PPO","2493.78","58.3","","1530.90","1160.93","1884.08","89","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2267.08","53","","5253.92","5253.92","5253.92","1 through 10","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2480.95","58","","12181.47","12181.47","12181.47","1 through 10","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2673.44","62.5","","1350.68","1350.68","1350.68","1 through 10","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1901.35","44.45","","1910.74","891.94","1910.74","1 through 10","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","both","","","4277.50","3208.12","WELLPOINT [1015]","HB CH WELLPOINT","3332.60","77.91","","1829.79","1561.50","2617.12","88","1901.35","3332.6","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4277.50","3208.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2536.56","59.3","","1359.46","1201.30","1689.00","61","2138.75","3355.7","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4277.50","3208.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2536.56","59.3","","1718.92","1718.92","1718.92","1 through 10","2138.75","3355.7","percent of total billed charges",""
"SYSTEM REPAIR ACUTE AC KNOTLESS","SUP-ITM-10269636","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4277.50","3208.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3355.70","78.45","","1910.74","1019.06","2344.84","74","2138.75","3355.7","percent of total billed charges",""
"SYSTEM SLING DESARA TV BLUE BX/5EA","SUP-ITM-10190840","CDM","C1771","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","1952.48","1215.31","1952.48","1 through 10","1193.48","2091.88","percent of total billed charges",""
"SYSTEM SLING DESARA TV BLUE BX/5EA","SUP-ITM-10190840","CDM","C1771","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","2735.63","2146.75","4736.42","1 through 10","1193.48","2091.88","percent of total billed charges",""
"SYSTEM SLING DESARA TV BLUE BX/5EA","SUP-ITM-10190840","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","1597.25","1552.67","1756.87","1 through 10","1342.5","2106.38","percent of total billed charges",""
"SYSTEM SLING DESARA TV BLUE BX/5EA","SUP-ITM-10190840","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","2647.39","1568.87","3176.87","1 through 10","1342.5","2106.38","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","464.71","67.87","1012.10","221","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","293.04","293.04","293.04","11","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","983.89","983.89","983.89","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2030.00","58","","677.18","677.18","677.18","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2187.50","62.5","","46.58","46.58","46.58","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","747.15","747.15","747.15","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","1141.67","481.21","1141.67","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.75","44.45","","76.54","76.54","76.54","1 through 10","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","273.64","94.28","1367.51","138","1555.75","2726.85","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","720.78","230.14","2010.94","427","1750","2745.75","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2075.50","59.3","","344.45","344.45","344.45","1 through 10","1750","2745.75","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","1120.13","1120.13","1120.13","1 through 10","1750","2745.75","percent of total billed charges",""
"SYSTEM STABILZATION 4.2X50MM 14MM NOTCH SYNDESMOSIS IMPLANT R3ACT","SUP-ITM-10297201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","456.17","105.33","1284.66","242","1750","2745.75","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","AETNA [1001]","HB CH AETNA HMO / PPO","2200.59","58.3","","464.71","67.87","1012.10","221","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2200.59","58.3","","293.04","293.04","293.04","11","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2000.54","53","","983.89","983.89","983.89","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2189.27","58","","677.18","677.18","677.18","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2359.13","62.5","","46.58","46.58","46.58","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2755.46","73","","747.15","747.15","747.15","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1677.81","44.45","","1141.67","481.21","1141.67","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1677.81","44.45","","76.54","76.54","76.54","1 through 10","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","both","","","3774.60","2830.95","WELLPOINT [1015]","HB CH WELLPOINT","2940.79","77.91","","273.64","94.28","1367.51","138","1677.81","2940.79","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3774.60","2830.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","2238.34","59.3","","720.78","230.14","2010.94","427","1887.3","2961.17","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3774.60","2830.95","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2238.34","59.3","","344.45","344.45","344.45","1 through 10","1887.3","2961.17","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3774.60","2830.95","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2961.17","78.45","","1120.13","1120.13","1120.13","1 through 10","1887.3","2961.17","percent of total billed charges",""
"SYSTEM STAPLE 15X15MM COMPRESSION OSSIOFIBER","SUP-ITM-10312019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3774.60","2830.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2961.17","78.45","","456.17","105.33","1284.66","242","1887.3","2961.17","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","AETNA [1001]","HB CH AETNA HMO / PPO","1827.71","58.3","","464.71","67.87","1012.10","221","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1827.71","58.3","","293.04","293.04","293.04","11","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1661.55","53","","983.89","983.89","983.89","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1818.30","58","","677.18","677.18","677.18","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1959.38","62.5","","46.58","46.58","46.58","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2288.55","73","","747.15","747.15","747.15","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1393.51","44.45","","1141.67","481.21","1141.67","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1393.51","44.45","","76.54","76.54","76.54","1 through 10","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","both","","","3135.00","2351.25","WELLPOINT [1015]","HB CH WELLPOINT","2442.48","77.91","","273.64","94.28","1367.51","138","1393.51","2442.48","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1859.06","59.3","","720.78","230.14","2010.94","427","1567.5","2459.41","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1859.06","59.3","","344.45","344.45","344.45","1 through 10","1567.5","2459.41","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2459.41","78.45","","1120.13","1120.13","1120.13","1 through 10","1567.5","2459.41","percent of total billed charges",""
"SYSTEM STAPLE COMPRESSION 11X10MM","SUP-ITM-10329247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3135.00","2351.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2459.41","78.45","","456.17","105.33","1284.66","242","1567.5","2459.41","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","AETNA [1001]","HB CH AETNA HMO / PPO","2324.71","58.3","","464.71","67.87","1012.10","221","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2324.71","58.3","","293.04","293.04","293.04","11","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.38","53","","983.89","983.89","983.89","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2312.75","58","","677.18","677.18","677.18","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2492.19","62.5","","46.58","46.58","46.58","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2910.88","73","","747.15","747.15","747.15","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.44","44.45","","1141.67","481.21","1141.67","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.44","44.45","","76.54","76.54","76.54","1 through 10","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","WELLPOINT [1015]","HB CH WELLPOINT","3106.66","77.91","","273.64","94.28","1367.51","138","1772.44","3106.66","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2364.59","59.3","","720.78","230.14","2010.94","427","1993.75","3128.19","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2364.59","59.3","","344.45","344.45","344.45","1 through 10","1993.75","3128.19","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3128.19","78.45","","1120.13","1120.13","1120.13","1 through 10","1993.75","3128.19","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.19","78.45","","456.17","105.33","1284.66","242","1993.75","3128.19","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","1 through 10","46.04","277.18","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","207.00","155.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.75","59.3","","117.79","117.79","128.70","1 through 10","14.19","176.44","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","154.53","154.53","154.54","1 through 10","14.19","176.44","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","190.00","142.50","AETNA [1001]","HB CH AETNA HMO / PPO","110.77","58.3","","104.90","104.90","104.90","1 through 10","36.98","222.6","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","190.00","142.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.67","59.3","","108.41","108.41","108.41","1 through 10","11.81","149.06","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","142.23","142.23","142.23","1 through 10","11.81","149.06","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","1 through 10","13.46","93.1","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","1 through 10","7.52","76.88","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","73.04","73.04","27","7.52","76.88","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","AETNA [1001]","HB CH AETNA HMO / PPO","312.86","58.3","","464.71","67.87","1012.10","221","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","312.86","58.3","","293.04","293.04","293.04","11","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.42","53","","983.89","983.89","983.89","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","311.25","58","","677.18","677.18","677.18","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","335.40","62.5","","46.58","46.58","46.58","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","391.75","73","","747.15","747.15","747.15","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.54","44.45","","1141.67","481.21","1141.67","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.54","44.45","","76.54","76.54","76.54","1 through 10","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","WELLPOINT [1015]","HB CH WELLPOINT","418.10","77.91","","273.64","94.28","1367.51","138","238.54","418.1","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.23","59.3","","720.78","230.14","2010.94","427","268.32","420.99","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","318.23","59.3","","344.45","344.45","344.45","1 through 10","268.32","420.99","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","420.99","78.45","","1120.13","1120.13","1120.13","1 through 10","268.32","420.99","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","420.99","78.45","","456.17","105.33","1284.66","242","268.32","420.99","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","AETNA [1001]","HB CH AETNA HMO / PPO","886.53","58.3","","464.71","67.87","1012.10","221","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","886.53","58.3","","293.04","293.04","293.04","11","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","805.94","53","","983.89","983.89","983.89","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","881.97","58","","677.18","677.18","677.18","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","950.40","62.5","","46.58","46.58","46.58","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1110.07","73","","747.15","747.15","747.15","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.92","44.45","","1141.67","481.21","1141.67","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.92","44.45","","76.54","76.54","76.54","1 through 10","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","WELLPOINT [1015]","HB CH WELLPOINT","1184.73","77.91","","273.64","94.28","1367.51","138","675.92","1184.73","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.74","59.3","","720.78","230.14","2010.94","427","760.32","1192.94","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","901.74","59.3","","344.45","344.45","344.45","1 through 10","760.32","1192.94","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1192.94","78.45","","1120.13","1120.13","1120.13","1 through 10","760.32","1192.94","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1192.94","78.45","","456.17","105.33","1284.66","242","760.32","1192.94","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","AETNA [1001]","HB CH AETNA HMO / PPO","1163.09","58.3","","464.71","67.87","1012.10","221","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1163.09","58.3","","293.04","293.04","293.04","11","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1057.35","53","","983.89","983.89","983.89","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1157.10","58","","677.18","677.18","677.18","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1246.88","62.5","","46.58","46.58","46.58","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1456.35","73","","747.15","747.15","747.15","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.78","44.45","","1141.67","481.21","1141.67","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.78","44.45","","76.54","76.54","76.54","1 through 10","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.00","1496.25","WELLPOINT [1015]","HB CH WELLPOINT","1554.30","77.91","","273.64","94.28","1367.51","138","886.78","1554.3","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.00","1496.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1183.04","59.3","","720.78","230.14","2010.94","427","997.5","1565.08","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.00","1496.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1183.04","59.3","","344.45","344.45","344.45","1 through 10","997.5","1565.08","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.00","1496.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1565.08","78.45","","1120.13","1120.13","1120.13","1 through 10","997.5","1565.08","percent of total billed charges",""
"TAP BONE 5.5MM CANNULATED PERCUTANEOUS","SUP-ITM-10088433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.00","1496.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1565.08","78.45","","456.17","105.33","1284.66","242","997.5","1565.08","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","AETNA [1001]","HB CH AETNA HMO / PPO","371.10","58.3","","464.71","67.87","1012.10","221","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","371.10","58.3","","293.04","293.04","293.04","11","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","337.37","53","","983.89","983.89","983.89","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","369.19","58","","677.18","677.18","677.18","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","397.84","62.5","","46.58","46.58","46.58","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","464.67","73","","747.15","747.15","747.15","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.94","44.45","","1141.67","481.21","1141.67","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.94","44.45","","76.54","76.54","76.54","1 through 10","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","WELLPOINT [1015]","HB CH WELLPOINT","495.93","77.91","","273.64","94.28","1367.51","138","282.94","495.93","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","377.47","59.3","","720.78","230.14","2010.94","427","318.27","499.37","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","377.47","59.3","","344.45","344.45","344.45","1 through 10","318.27","499.37","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","499.37","78.45","","1120.13","1120.13","1120.13","1 through 10","318.27","499.37","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","499.37","78.45","","456.17","105.33","1284.66","242","318.27","499.37","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","AETNA [1001]","HB CH AETNA HMO / PPO","122.43","58.3","","464.71","67.87","1012.10","221","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","122.43","58.3","","293.04","293.04","293.04","11","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","111.30","53","","983.89","983.89","983.89","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","121.80","58","","677.18","677.18","677.18","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","131.25","62.5","","46.58","46.58","46.58","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","747.15","747.15","747.15","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","1141.67","481.21","1141.67","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","76.54","76.54","76.54","1 through 10","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB CH WELLPOINT","163.61","77.91","","273.64","94.28","1367.51","138","93.35","163.61","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.53","59.3","","720.78","230.14","2010.94","427","105","164.75","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","124.53","59.3","","344.45","344.45","344.45","1 through 10","105","164.75","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","1120.13","1120.13","1120.13","1 through 10","105","164.75","percent of total billed charges",""
"TAPE TIGER LABRAL BX/12EA","SUP-ITM-10137707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","456.17","105.33","1284.66","242","105","164.75","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","AETNA [1001]","HB CH AETNA HMO / PPO","164.41","58.3","","1530.90","1160.93","1884.08","89","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","149.46","53","","5253.92","5253.92","5253.92","1 through 10","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","163.56","58","","12181.47","12181.47","12181.47","1 through 10","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","176.25","62.5","","1350.68","1350.68","1350.68","1 through 10","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","125.35","44.45","","1910.74","891.94","1910.74","1 through 10","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","WELLPOINT [1015]","HB CH WELLPOINT","219.71","77.91","","1829.79","1561.50","2617.12","88","125.35","219.71","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","282.00","211.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","167.23","59.3","","1359.46","1201.30","1689.00","61","141","221.23","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","282.00","211.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","167.23","59.3","","1718.92","1718.92","1718.92","1 through 10","141","221.23","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","221.23","78.45","","1910.74","1019.06","2344.84","74","141","221.23","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","AETNA [1001]","HB CH AETNA HMO / PPO","172.63","58.3","","1530.90","1160.93","1884.08","89","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","156.93","53","","5253.92","5253.92","5253.92","1 through 10","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","171.74","58","","12181.47","12181.47","12181.47","1 through 10","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","185.06","62.5","","1350.68","1350.68","1350.68","1 through 10","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.62","44.45","","1910.74","891.94","1910.74","1 through 10","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","296.10","222.07","WELLPOINT [1015]","HB CH WELLPOINT","230.69","77.91","","1829.79","1561.50","2617.12","88","131.62","230.69","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","296.10","222.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","175.59","59.3","","1359.46","1201.30","1689.00","61","148.05","232.29","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","296.10","222.07","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","175.59","59.3","","1718.92","1718.92","1718.92","1 through 10","148.05","232.29","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","296.10","222.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","232.29","78.45","","1910.74","1019.06","2344.84","74","148.05","232.29","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","AETNA [1001]","HB CH AETNA HMO / PPO","760.82","58.3","","1530.90","1160.93","1884.08","89","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.65","53","","5253.92","5253.92","5253.92","1 through 10","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","756.90","58","","12181.47","12181.47","12181.47","1 through 10","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","815.63","62.5","","1350.68","1350.68","1350.68","1 through 10","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.07","44.45","","1910.74","891.94","1910.74","1 through 10","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","WELLPOINT [1015]","HB CH WELLPOINT","1016.73","77.91","","1829.79","1561.50","2617.12","88","580.07","1016.73","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.87","59.3","","1359.46","1201.30","1689.00","61","652.5","1023.77","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","773.87","59.3","","1718.92","1718.92","1718.92","1 through 10","652.5","1023.77","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.77","78.45","","1910.74","1019.06","2344.84","74","652.5","1023.77","percent of total billed charges",""
"Tau Phosphorylated Each","PX-30003839","CDM","84393","CPT","0301","RC","","","","outpatient","","","720.00","540.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","360.72","50.1","","360.78","360.78","360.78","1 through 10","288","564.84","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","729.00","546.75","AETNA [1001]","HB CH AETNA HMO / PPO","425.01","58.3","","402.00","402.00","402.00","65","98","692.55","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","729.00","546.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","532.17","73","","709.00","709.00","709.00","1 through 10","98","692.55","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","729.00","546.75","TRICARE [160005]","HB NWH TRICARE","692.55","95","","120.50","114.48","120.50","1 through 10","98","692.55","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.04","44.45","","521.71","323.02","545.08","1 through 10","98","692.55","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","729.00","546.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","432.30","59.3","","415.47","415.47","415.47","50","77.26","571.9","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","571.90","78.45","","545.08","323.02","545.08","54","77.26","571.9","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","419.00","314.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","241.76","57.7","","245.42","245.42","245.42","1 through 10","136.8","328.71","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","121.91","121.91","121.91","1 through 10","18.27","171.95","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","181.00","135.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.33","59.3","","125.99","125.99","125.99","1 through 10","14.12","141.99","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.99","78.45","","165.29","97.95","215.00","1 through 10","14.12","141.99","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","121.91","121.91","121.91","1 through 10","18.27","141.55","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","125.99","125.99","125.99","1 through 10","14.12","116.89","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","165.29","97.95","215.00","1 through 10","14.12","116.89","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","AETNA [1001]","HB CH AETNA HMO / PPO","102.61","58.3","","121.91","121.91","121.91","1 through 10","18.27","167.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.37","59.3","","125.99","125.99","125.99","1 through 10","14.12","138.07","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.07","78.45","","165.29","97.95","215.00","1 through 10","14.12","138.07","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","121.91","121.91","121.91","1 through 10","18.27","219.45","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","125.99","125.99","125.99","1 through 10","14.12","181.22","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","165.29","97.95","215.00","1 through 10","14.12","181.22","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","220.00","165.00","AETNA [1001]","HB CH AETNA HMO / PPO","128.26","58.3","","121.91","121.91","121.91","1 through 10","18.27","209","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","220.00","165.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","130.46","59.3","","125.99","125.99","125.99","1 through 10","14.12","172.59","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","172.59","78.45","","165.29","97.95","215.00","1 through 10","14.12","172.59","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","75.48","56.61","AETNA [1001]","HB CH AETNA HMO / PPO","44.00","58.3","","42.80","42.80","42.80","1 through 10","33.55","128.27","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","75.48","56.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","55.10","73","","42.80","42.80","42.80","1 through 10","33.55","128.27","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","75.48","56.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.55","44.45","","83.05","83.05","83.05","1 through 10","33.55","128.27","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","75.48","56.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.40","52.2","","38.87","38.87","38.87","15","37.74","59.21","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","75.48","56.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","59.21","78.45","","83.05","75.48","84.00","11","37.74","59.21","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","464.71","67.87","1012.10","221","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","293.04","293.04","293.04","11","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","983.89","983.89","983.89","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1392.00","58","","677.18","677.18","677.18","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1500.00","62.5","","46.58","46.58","46.58","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","747.15","747.15","747.15","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","1141.67","481.21","1141.67","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","76.54","76.54","76.54","1 through 10","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","273.64","94.28","1367.51","138","1066.8","1869.84","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","720.78","230.14","2010.94","427","1200","1882.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1423.20","59.3","","344.45","344.45","344.45","1 through 10","1200","1882.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1120.13","1120.13","1120.13","1 through 10","1200","1882.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","456.17","105.33","1284.66","242","1200","1882.8","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","AETNA [1001]","HB CH AETNA HMO / PPO","2105.80","58.3","","464.71","67.87","1012.10","221","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2105.80","58.3","","293.04","293.04","293.04","11","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1914.36","53","","983.89","983.89","983.89","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2094.96","58","","677.18","677.18","677.18","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2257.50","62.5","","46.58","46.58","46.58","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2636.76","73","","747.15","747.15","747.15","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","1141.67","481.21","1141.67","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","76.54","76.54","76.54","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","WELLPOINT [1015]","HB CH WELLPOINT","2814.11","77.91","","273.64","94.28","1367.51","138","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2141.92","59.3","","720.78","230.14","2010.94","427","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2141.92","59.3","","344.45","344.45","344.45","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","456.17","105.33","1284.66","242","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","AETNA [1001]","HB CH AETNA HMO / PPO","2105.80","58.3","","464.71","67.87","1012.10","221","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2105.80","58.3","","293.04","293.04","293.04","11","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1914.36","53","","983.89","983.89","983.89","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2094.96","58","","677.18","677.18","677.18","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2257.50","62.5","","46.58","46.58","46.58","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2636.76","73","","747.15","747.15","747.15","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","1141.67","481.21","1141.67","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","76.54","76.54","76.54","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","WELLPOINT [1015]","HB CH WELLPOINT","2814.11","77.91","","273.64","94.28","1367.51","138","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2141.92","59.3","","720.78","230.14","2010.94","427","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2141.92","59.3","","344.45","344.45","344.45","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","456.17","105.33","1284.66","242","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","AETNA [1001]","HB CH AETNA HMO / PPO","2105.80","58.3","","464.71","67.87","1012.10","221","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2105.80","58.3","","293.04","293.04","293.04","11","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1914.36","53","","983.89","983.89","983.89","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2094.96","58","","677.18","677.18","677.18","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2257.50","62.5","","46.58","46.58","46.58","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2636.76","73","","747.15","747.15","747.15","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","1141.67","481.21","1141.67","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.53","44.45","","76.54","76.54","76.54","1 through 10","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","3612.00","2709.00","WELLPOINT [1015]","HB CH WELLPOINT","2814.11","77.91","","273.64","94.28","1367.51","138","1605.53","2814.11","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2141.92","59.3","","720.78","230.14","2010.94","427","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2141.92","59.3","","344.45","344.45","344.45","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1806","2833.61","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2833.61","78.45","","456.17","105.33","1284.66","242","1806","2833.61","percent of total billed charges",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","42544.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24490.62","","Standard inlier is a Case rate ($24,490.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $35,037, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,476.34) for the length of stay and the standard reimbursement.","23377.41","23377.41","23377.41","1 through 10","9868.93","47311.62","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","33866.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","29489.09","","Standard inlier is a Case rate ($29,489.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $41,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,186.09) for the length of stay and the standard reimbursement.","28149.06","28149.06","28149.06","1 through 10","9868.93","47311.62","case rate",""
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","29940.14","22455.10","MEDICARE [2001]","HB NWH MEDICARE","14164.51","","Case rate ($14,164.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,233.72, add-ons for qualifying new technology services are included. If operating cost exceeds $58,375.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,926.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,180.05. The transfer operating threshold is the transfer adjustment factor * $13,233.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $984.46. The transfer capital threshold is the transfer adjustment factor * $984.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14790.60","14790.60","14817.19","1 through 10","12624.74","15263.03","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","29940.14","22455.10","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","12624.74","","Case rate ($12,882.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,233.72, add-ons for qualifying new technology services are included. If operating cost exceeds $58,375.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,926.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,897.93. The transfer operating threshold is the transfer adjustment factor * $13,233.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $984.46. The transfer capital threshold is the transfer adjustment factor * $984.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8440.21","8440.21","8440.21","1 through 10","12624.74","15263.03","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","20185.79","15139.34","MEDICARE [2001]","HB NWH MEDICARE","7738.63","","Case rate ($7,738.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,949.67, add-ons for qualifying new technology services are included. If operating cost exceeds $53,091.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,533.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,147.24. The transfer operating threshold is the transfer adjustment factor * $7,949.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.38. The transfer capital threshold is the transfer adjustment factor * $591.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8244.25","8244.25","8259.07","1 through 10","7583.86","9168.7","other","Inpatient Replacement Plans DRG"
"Tenex Procedure Hand/Fingers","PX-36000486","CDM","26989","CPT","0361","RC","","","","outpatient","","","3714.00","2785.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1860.71","50.1","","1492.50","1194.00","1492.50","1 through 10","1485.6","2913.63","percent of total billed charges",""
"Tenex Procedure Hip","PX-36000490","CDM","27299","CPT","0361","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB NWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","2868.22","other","OPPS APC"
"Tenex Procedure Hip","PX-36000490","CDM","27299","CPT","0361","RC","","","","outpatient","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2366.05","78.45","","25790.16","25790.16","25790.16","1 through 10","567.68","2366.05","percent of total billed charges",""
"Tenex Procedure Knee","PX-36000491","CDM","27599","CPT","0361","RC","","","","both","","","7994.00","5995.50","MEDICARE [2001]","HB NWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","7602.29","other","OPPS APC"
"Tenex Procedure Shoulder","PX-36000489","CDM","23929","CPT","0361","RC","","","","outpatient","","","2543.00","1907.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1274.04","50.1","","186.10","186.10","186.10","1 through 10","567.68","1994.98","percent of total billed charges",""
"Tenex Procedure Shoulder","PX-36000489","CDM","23929","CPT","0361","RC","","","","outpatient","","","2543.00","1907.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1508.00","59.3","","9413.40","9413.40","9413.40","1 through 10","567.68","1994.98","percent of total billed charges",""
"Tenex Procedure Shoulder","PX-36000489","CDM","23929","CPT","0361","RC","","","","outpatient","","","2543.00","1907.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1467.31","57.7","","2473.00","2473.00","2473.00","1 through 10","567.68","1994.98","percent of total billed charges",""
"Tenex Procedure Wrist","PX-36000487","CDM","25999","CPT","0361","RC","","","","outpatient","","","2613.00","1959.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2049.90","78.45","","3296.61","3296.61","3296.61","1 through 10","1045.2","2049.9","percent of total billed charges",""
"Tenotomy Abductor Hip Percutaneous","PX-76002785","CDM","27599","CPT","0761","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB NWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","2868.22","other","OPPS APC"
"Tenotomy Abductor Hip Percutaneous","PX-98302351","CDM","27599","CPT","0983","RC","","","","both","","","1948.00","1461.00","MEDICARE [2001]","HB NWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1852.55","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0720","RC","","","","inpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","401.71","70.6","","251.95","251.95","251.95","1 through 10","318.64","401.71","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","AETNA [1001]","HB CH AETNA HMO / PPO","331.73","58.3","","313.55","313.55","627.10","30","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","CHAMPVA [160001]","HB NWH TRICARE","540.55","95","","553.00","14.03","553.00","1 through 10","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","487.83","487.83","487.83","15","165.93","540.55","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","429.76","341.02","644.64","57","165.93","540.55","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","62.53","62.53","62.54","39","165.93","540.55","per diem",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($243). Procedure 2, Per diem ($121.50). Procedures 3 - 9999, Per diem ($60.75).","73.57","71.44","73.57","51","165.93","540.55","per diem",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($256). Procedure 2, Per diem ($128). Procedures 3 - 9999, Per diem ($64).","73.57","73.57","77.25","1 through 10","165.93","540.55","per diem",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","81.07","81.07","81.07","151","165.93","540.55","per diem",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","415.37","73","","313.55","313.55","313.55","1 through 10","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","TRICARE [160005]","HB NWH TRICARE","540.55","95","","14.03","14.03","14.03","11","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.92","44.45","","425.15","425.15","425.15","1 through 10","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","413.17","413.17","413.17","1 through 10","165.93","540.55","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","569.00","426.75","WELLPOINT [1015]","HB CH WELLPOINT","443.31","77.91","","435.54","435.54","435.55","33","165.93","540.55","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","337.42","59.3","","324.06","324.06","324.06","193","165.93","608.75","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","389.94","375.00","389.94","151","165.93","608.75","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","409.85","394.91","487.83","87","165.93","608.75","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","394.91","394.91","394.91","1 through 10","165.93","608.75","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","487.83","487.83","487.83","1 through 10","165.93","608.75","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","446.38","78.45","","425.15","251.95","425.15","190","165.93","608.75","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2319.00","1739.25","MEDICARE [2001]","HB NWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","351.32","1806.73","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","outpatient","","","2319.00","1739.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1030.80","44.45","","1733.64","1733.64","1733.64","1 through 10","224.5","1819.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","297.00","222.75","AETNA [1001]","HB CH AETNA HMO / PPO","173.15","58.3","","163.86","163.86","163.86","79","24.96","282.15","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","297.00","222.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","216.81","73","","163.86","163.86","169.35","1 through 10","24.96","282.15","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","297.00","222.75","TRICARE [160005]","HB NWH TRICARE","282.15","95","","30.69","29.16","30.69","1 through 10","24.96","282.15","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","297.00","222.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","176.12","59.3","","169.35","169.35","169.35","80","26.26","233","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.02","44.45","","131.67","129.76","222.18","1 through 10","26.26","233","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","233.00","78.45","","222.18","131.67","222.18","62","26.26","233","percent of total billed charges",""
"Testosterone Response Panel","PX-30000046","CDM","80414","CPT","0300","RC","","","","both","","","637.00","477.75","AETNA [1001]","HB CH AETNA HMO / PPO","371.37","58.3","","232.47","232.47","232.47","1 through 10","50.61","605.15","percent of total billed charges",""
"Testosterone Response Panel","PX-30000046","CDM","80414","CPT","0300","RC","","","","outpatient","","","637.00","477.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","499.73","78.45","","315.21","186.80","315.21","1 through 10","53.25","499.73","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","AETNA [1001]","HB CH AETNA HMO / PPO","123.01","58.3","","116.24","116.24","116.24","173","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","154.03","73","","149.65","149.65","149.65","1 through 10","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","154.03","73","","116.24","23.23","120.13","1 through 10","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","TRICARE [160005]","HB NWH TRICARE","200.45","95","","31.10","29.55","31.10","1 through 10","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.79","44.45","","93.40","92.05","157.60","1 through 10","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.79","44.45","","157.60","157.60","157.60","1 through 10","25.29","200.45","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","211.00","158.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.12","59.3","","120.13","120.13","120.13","175","26.62","165.53","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","165.53","78.45","","157.60","93.40","157.60","170","26.62","165.53","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","both","","","3640.00","2730.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2657.20","73","","2006.61","2006.61","2006.61","1 through 10","585.95","3458","percent of total billed charges",""
"Theophylline","PX-30000190","CDM","80198","CPT","0301","RC","","","","both","","","117.00","87.75","AETNA [1001]","HB CH AETNA HMO / PPO","68.21","58.3","","64.64","64.64","64.64","1 through 10","13.86","111.15","percent of total billed charges",""
"Theophylline","PX-30000190","CDM","80198","CPT","0301","RC","","","","both","","","117.00","87.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.01","44.45","","87.64","87.64","87.64","1 through 10","13.86","111.15","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-42000116","CDM","97129","CPT","0421","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","22.49","364.8","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-43000122","CDM","97129","CPT","0431","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","22.49","364.8","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-44000096","CDM","97129","CPT","0441","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","22.49","410.4","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-42000117","CDM","97130","CPT","0421","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","21.83","364.8","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-43000123","CDM","97130","CPT","0431","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","21.83","364.8","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-44000097","CDM","97130","CPT","0441","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","21.83","410.4","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000193","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000193","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000193","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001448","CDM","80299","CPT","0301","RC","","","","both","","","265.00","198.75","AETNA [1001]","HB CH AETNA HMO / PPO","154.50","58.3","","121.91","121.91","121.91","1 through 10","18.27","251.75","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001448","CDM","80299","CPT","0301","RC","","","","outpatient","","","265.00","198.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","157.15","59.3","","125.99","125.99","125.99","1 through 10","14.12","207.89","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001448","CDM","80299","CPT","0301","RC","","","","outpatient","","","265.00","198.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.89","78.45","","165.29","97.95","215.00","1 through 10","14.12","207.89","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001474","CDM","80299","CPT","0300","RC","","","","both","","","161.00","120.75","AETNA [1001]","HB CH AETNA HMO / PPO","93.86","58.3","","121.91","121.91","121.91","1 through 10","18.27","152.95","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001474","CDM","80299","CPT","0300","RC","","","","outpatient","","","161.00","120.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.47","59.3","","125.99","125.99","125.99","1 through 10","14.12","126.3","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001474","CDM","80299","CPT","0300","RC","","","","outpatient","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.30","78.45","","165.29","97.95","215.00","1 through 10","14.12","126.3","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001475","CDM","80299","CPT","0300","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","121.91","121.91","121.91","1 through 10","18.27","215.65","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001475","CDM","80299","CPT","0300","RC","","","","outpatient","","","227.00","170.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.61","59.3","","125.99","125.99","125.99","1 through 10","14.12","178.08","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001475","CDM","80299","CPT","0300","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","165.29","97.95","215.00","1 through 10","14.12","178.08","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001476","CDM","80299","CPT","0300","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","218.5","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001476","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001476","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","97.95","215.00","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001477","CDM","80299","CPT","0300","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","121.91","121.91","121.91","1 through 10","18.27","172.9","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001477","CDM","80299","CPT","0300","RC","","","","outpatient","","","182.00","136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.93","59.3","","125.99","125.99","125.99","1 through 10","14.12","142.78","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001477","CDM","80299","CPT","0300","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","165.29","97.95","215.00","1 through 10","14.12","142.78","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001478","CDM","80299","CPT","0300","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","218.5","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001478","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","125.99","125.99","125.99","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001478","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","97.95","215.00","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001479","CDM","80299","CPT","0300","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","159.6","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001479","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","125.99","125.99","125.99","1 through 10","14.12","131.8","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001479","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","165.29","97.95","215.00","1 through 10","14.12","131.8","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","125.31","125.31","125.31","71","49.13","232.43","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","43.67","43.67","87.33","36","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","41.59","83.17","144","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","FALLON HEALTH [1008]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","HUMANA [1012]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.90","82.90","82.90","1 through 10","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42.26","42.26","84.52","1435","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.42","82.83","133","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.90","44.45","","100.69","100.69","100.69","11","49.13","232.43","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","42.26","84.52","38","49.13","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","227.00","170.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.61","59.3","","129.51","129.51","129.51","63","98.67","204.65","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","169.90","100.69","169.91","19","98.67","204.65","percent of total billed charges",""
"Thiopurine Metabolites, Whole Blood","PX-30003691","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Thiopurine Metabolites, Whole Blood","PX-30003691","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Thiopurine Metabolites, Whole Blood","PX-30003691","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","both","","","1567.00","1175.25","AETNA [1001]","HB CH AETNA HMO / PPO","913.56","58.3","","864.11","864.11","864.11","1 through 10","620.01","1220.85","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","2190.90","412.50","9264.59","16","200.03","350.6","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","1903.20","1903.20","3826.66","1 through 10","200.03","350.6","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","2186.25","2186.25","2186.25","32","200.03","350.6","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","5556.60","5556.60","5556.60","1 through 10","200.03","350.6","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","1955.15","885.83","3150.40","26","200.03","350.6","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","831.03","253.22","2394.88","18","225","353.03","percent of total billed charges",""
"THORACOLUMBAR ROD 5.5X80MM FIREBIRD TITANIUM","SUP-ITM-10083504","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","2481.69","1563.74","8149.28","1 through 10","225","353.03","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","464.71","67.87","1012.10","221","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","293.04","293.04","293.04","11","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","983.89","983.89","983.89","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","417.60","58","","677.18","677.18","677.18","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","450.00","62.5","","46.58","46.58","46.58","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","747.15","747.15","747.15","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","1141.67","481.21","1141.67","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","76.54","76.54","76.54","1 through 10","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","273.64","94.28","1367.51","138","320.04","560.95","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","720.78","230.14","2010.94","427","360","564.84","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","426.96","59.3","","344.45","344.45","344.45","1 through 10","360","564.84","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1120.13","1120.13","1120.13","1 through 10","360","564.84","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X30MM SPHERX DBR II PREBENT TITANIUM DUAL BALL","SUP-ITM-10107808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","456.17","105.33","1284.66","242","360","564.84","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","2190.90","412.50","9264.59","16","1944.69","3408.56","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2537.50","58","","1903.20","1903.20","3826.66","1 through 10","1944.69","3408.56","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2734.38","62.5","","2186.25","2186.25","2186.25","32","1944.69","3408.56","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","5556.60","5556.60","5556.60","1 through 10","1944.69","3408.56","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","1955.15","885.83","3150.40","26","1944.69","3408.56","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","831.03","253.22","2394.88","18","2187.5","3432.19","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X22MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2481.69","1563.74","8149.28","1 through 10","2187.5","3432.19","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","2190.90","412.50","9264.59","16","3556","6232.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4640.00","58","","1903.20","1903.20","3826.66","1 through 10","3556","6232.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5000.00","62.5","","2186.25","2186.25","2186.25","32","3556","6232.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","5556.60","5556.60","5556.60","1 through 10","3556","6232.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","1955.15","885.83","3150.40","26","3556","6232.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","831.03","253.22","2394.88","18","4000","6276","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X38 28MM 8DEG BRIGADE PEEK","SUP-ITM-10082724","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","2481.69","1563.74","8149.28","1 through 10","4000","6276","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","2190.90","412.50","9264.59","16","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","1903.20","1903.20","3826.66","1 through 10","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","2186.25","2186.25","2186.25","32","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","5556.60","5556.60","5556.60","1 through 10","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1955.15","885.83","3150.40","26","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","831.03","253.22","2394.88","18","2000","3138","percent of total billed charges",""
"THORACOLUMBAR SPACER 6X22MM VERTE STACK PEEK","SUP-ITM-10110965","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2481.69","1563.74","8149.28","1 through 10","2000","3138","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","2190.90","412.50","9264.59","16","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2320.00","58","","1903.20","1903.20","3826.66","1 through 10","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2500.00","62.5","","2186.25","2186.25","2186.25","32","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","5556.60","5556.60","5556.60","1 through 10","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","1955.15","885.83","3150.40","26","1778","3116.4","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","831.03","253.22","2394.88","18","2000","3138","percent of total billed charges",""
"THORACOLUMBAR SPACER 8.0X11.0 30.0MM 0DEG AVS PL PEEK","SUP-ITM-10047275","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2481.69","1563.74","8149.28","1 through 10","2000","3138","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","15.74","126.35","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.87","59.3","","75.59","75.59","75.59","18","16.56","104.34","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.12","44.45","","99.17","99.17","99.17","1 through 10","16.56","104.34","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","104.34","78.45","","99.18","58.77","99.18","17","16.56","104.34","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","91.93","37","15.59","114.95","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","88.33","73","","66.91","66.91","66.91","1 through 10","15.59","114.95","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","19.17","19.17","19.17","1 through 10","15.59","114.95","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","90.72","90.72","90.72","1 through 10","15.59","114.95","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","34","15.29","94.92","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","90.72","28","15.29","94.92","percent of total billed charges",""
"Thyroid Activity (Tbg)","PX-30000700","CDM","84442","CPT","0301","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","93.02","93.02","93.02","1 through 10","15.25","97.28","percent of total billed charges",""
"Thyroid Lobectomy,Unilat","PX-76002285","CDM","60220","CPT","0761","RC","","","","both","","","12712.00","9534.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","5453.45","9903.92","per diem",""
"Thyroid Lobectomy,Unilat","PX-76002285","CDM","60220","CPT","0761","RC","","","","outpatient","","","12712.00","9534.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6237.78","49.07","","7589.12","7589.12","7589.12","1 through 10","5084.8","9972.56","percent of total billed charges",""
"Thyroid Lobectomy,Unilat","PX-76002285","CDM","60220","CPT","0761","RC","","","","outpatient","","","12712.00","9534.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9972.56","78.45","","10901.38","10901.38","10901.38","1 through 10","5084.8","9972.56","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0300","RC","","","","inpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.08","70.6","","87.48","87.48","87.48","1 through 10","110.32","139.08","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","AETNA [1001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","108.86","1348","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","140.16","140.16","140.16","1 through 10","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","108.86","1 through 10","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","108.86","108.86","140.16","1 through 10","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","TRICARE [160005]","HB NWH TRICARE","187.15","95","","20.24","19.23","20.24","37","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","187.15","95","","16.80","16.80","16.80","1 through 10","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","147.61","87.48","147.61","47","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","87.48","87.48","147.61","1 through 10","16.46","187.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","112.51","112.51","1347","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","116.82","59.3","","109.82","109.82","109.82","1 through 10","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","141.04","147.61","1 through 10","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","87.48","147.61","1153","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","233.04","233.04","233.04","14","49.84","401.85","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","423.00","317.25","TRICARE [160005]","HB NWH TRICARE","401.85","95","","61.29","61.29","61.29","1 through 10","49.84","401.85","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","240.85","240.85","240.85","18","52.45","331.84","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.84","78.45","","315.98","181.96","315.98","16","52.45","331.84","percent of total billed charges",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","","","","inpatient","","","64853.19","48639.89","MEDICARE [2001]","HB NWH MEDICARE","14283.59","","Case rate ($14,283.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,344.97, add-ons for qualifying new technology services are included. If operating cost exceeds $58,487.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,934.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,290.85. The transfer operating threshold is the transfer adjustment factor * $13,344.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.74. The transfer capital threshold is the transfer adjustment factor * $992.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14430.92","14430.92","14430.92","1 through 10","12730.88","14925.4677","other","Inpatient DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures With McC","625","MS-DRG","","","","","","","","inpatient","","","77932.03","58449.02","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","26950.90","","Case rate ($26,165.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $26,879.51, add-ons for qualifying new technology services are included. If operating cost exceeds $72,021.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,941.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $24,166.35. The transfer operating threshold is the transfer adjustment factor * $26,879.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,999.57. The transfer capital threshold is the transfer adjustment factor * $1,999.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25668.68","25668.68","25668.68","1 through 10","25642.6","28352.7519","other","Inpatient DRG"
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","415","8.84","97.85","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.19","73","","70.81","8.12","70.81","1 through 10","8.84","97.85","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB NWH TRICARE","97.85","95","","10.87","10.33","10.87","16","8.84","97.85","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","44.45","","76.88","45.56","76.88","21","8.84","97.85","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","44.45","","45.56","45.56","45.56","1 through 10","8.84","97.85","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","58.60","394","9.29","80.8","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","45.56","76.88","364","9.29","80.8","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","1 through 10","6.73","56.05","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","AETNA [1001]","HB CH AETNA HMO / PPO","2031.22","58.3","","464.71","67.87","1012.10","221","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.22","58.3","","293.04","293.04","293.04","11","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.56","53","","983.89","983.89","983.89","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2020.77","58","","677.18","677.18","677.18","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2177.55","62.5","","46.58","46.58","46.58","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.38","73","","747.15","747.15","747.15","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.67","44.45","","1141.67","481.21","1141.67","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.67","44.45","","76.54","76.54","76.54","1 through 10","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.08","2613.06","WELLPOINT [1015]","HB CH WELLPOINT","2714.45","77.91","","273.64","94.28","1367.51","138","1548.67","2714.45","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.08","2613.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.06","59.3","","720.78","230.14","2010.94","427","1742.04","2733.26","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.08","2613.06","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2066.06","59.3","","344.45","344.45","344.45","1 through 10","1742.04","2733.26","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.08","2613.06","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2733.26","78.45","","1120.13","1120.13","1120.13","1 through 10","1742.04","2733.26","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.08","2613.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.26","78.45","","456.17","105.33","1284.66","242","1742.04","2733.26","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","AETNA [1001]","HB CH AETNA HMO / PPO","3024.67","58.3","","464.71","67.87","1012.10","221","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3024.67","58.3","","293.04","293.04","293.04","11","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2749.70","53","","983.89","983.89","983.89","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3009.11","58","","677.18","677.18","677.18","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3242.58","62.5","","46.58","46.58","46.58","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3787.33","73","","747.15","747.15","747.15","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.12","44.45","","1141.67","481.21","1141.67","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.12","44.45","","76.54","76.54","76.54","1 through 10","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","both","","","5188.12","3891.09","WELLPOINT [1015]","HB CH WELLPOINT","4042.06","77.91","","273.64","94.28","1367.51","138","2306.12","4042.06","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","3076.56","59.3","","720.78","230.14","2010.94","427","2594.06","4070.08","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3076.56","59.3","","344.45","344.45","344.45","1 through 10","2594.06","4070.08","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4070.08","78.45","","1120.13","1120.13","1120.13","1 through 10","2594.06","4070.08","percent of total billed charges",""
"TIBIA PLATE 95MM 2 HOLE BONE AXSOS TITANIUM PROXIMALIMAL LATERAL RIGHT","SUP-ITM-10144618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5188.12","3891.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4070.08","78.45","","456.17","105.33","1284.66","242","2594.06","4070.08","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","AETNA [1001]","HB CH AETNA HMO / PPO","3152.01","58.3","","1530.90","1160.93","1884.08","89","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2865.47","53","","5253.92","5253.92","5253.92","1 through 10","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3135.79","58","","12181.47","12181.47","12181.47","1 through 10","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3379.09","62.5","","1350.68","1350.68","1350.68","1 through 10","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2403.21","44.45","","1910.74","891.94","1910.74","1 through 10","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","both","","","5406.54","4054.90","WELLPOINT [1015]","HB CH WELLPOINT","4212.24","77.91","","1829.79","1561.50","2617.12","88","2403.21","4212.24","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5406.54","4054.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","3206.08","59.3","","1359.46","1201.30","1689.00","61","2703.27","4241.43","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5406.54","4054.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3206.08","59.3","","1718.92","1718.92","1718.92","1 through 10","2703.27","4241.43","percent of total billed charges",""
"TIBIA PLATE L 175MM 10 HOLE BONE AXSOS TITANIUM DISTAL MEDIAL LEFT","SUP-ITM-10186936","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5406.54","4054.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4241.43","78.45","","1910.74","1019.06","2344.84","74","2703.27","4241.43","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","AETNA [1001]","HB CH AETNA HMO / PPO","3238.15","58.3","","464.71","67.87","1012.10","221","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3238.15","58.3","","293.04","293.04","293.04","11","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2943.77","53","","983.89","983.89","983.89","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3221.48","58","","677.18","677.18","677.18","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","3471.43","62.5","","46.58","46.58","46.58","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4054.62","73","","747.15","747.15","747.15","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2468.88","44.45","","1141.67","481.21","1141.67","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2468.88","44.45","","76.54","76.54","76.54","1 through 10","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","both","","","5554.28","4165.71","WELLPOINT [1015]","HB CH WELLPOINT","4327.34","77.91","","273.64","94.28","1367.51","138","2468.88","4327.34","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5554.28","4165.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","3293.69","59.3","","720.78","230.14","2010.94","427","2777.14","4357.33","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5554.28","4165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","3293.69","59.3","","344.45","344.45","344.45","1 through 10","2777.14","4357.33","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5554.28","4165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","4357.33","78.45","","1120.13","1120.13","1120.13","1 through 10","2777.14","4357.33","percent of total billed charges",""
"TIBIA PLATE L 201MM 12 HOLE AXSOS TITANIUM DISTAL MEDIAL RIGHT","SUP-ITM-10186929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5554.28","4165.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4357.33","78.45","","456.17","105.33","1284.66","242","2777.14","4357.33","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","AETNA [1001]","HB CH AETNA HMO / PPO","2782.08","58.3","","1530.90","1160.93","1884.08","89","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2529.16","53","","5253.92","5253.92","5253.92","1 through 10","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2767.76","58","","12181.47","12181.47","12181.47","1 through 10","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2982.50","62.5","","1350.68","1350.68","1350.68","1 through 10","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2121.15","44.45","","1910.74","891.94","1910.74","1 through 10","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","WELLPOINT [1015]","HB CH WELLPOINT","3717.87","77.91","","1829.79","1561.50","2617.12","88","2121.15","3717.87","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4772.00","3579.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2829.80","59.3","","1359.46","1201.30","1689.00","61","2386","3743.63","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4772.00","3579.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2829.80","59.3","","1718.92","1718.92","1718.92","1 through 10","2386","3743.63","percent of total billed charges",""
"TIBIAL BASEPLATE SM SIZE 2 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4772.00","3579.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3743.63","78.45","","1910.74","1019.06","2344.84","74","2386","3743.63","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1530.90","1160.93","1884.08","89","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","5253.92","5253.92","5253.92","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","12181.47","12181.47","12181.47","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","1350.68","1350.68","1350.68","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1910.74","891.94","1910.74","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","1829.79","1561.50","2617.12","88","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1359.46","1201.30","1689.00","61","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1718.92","1718.92","1718.92","1 through 10","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 1 RIGHT MEDIAL KNEE JOURNEY II UNI","SUP-ITM-10281451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1910.74","1019.06","2344.84","74","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1530.90","1160.93","1884.08","89","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","5253.92","5253.92","5253.92","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","12181.47","12181.47","12181.47","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","1350.68","1350.68","1350.68","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1910.74","891.94","1910.74","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","1829.79","1561.50","2617.12","88","840.11","1472.5","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1359.46","1201.30","1689.00","61","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1718.92","1718.92","1718.92","1 through 10","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1910.74","1019.06","2344.84","74","945","1482.71","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1530.90","1160.93","1884.08","89","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","5253.92","5253.92","5253.92","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1096.20","58","","12181.47","12181.47","12181.47","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1181.25","62.5","","1350.68","1350.68","1350.68","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","1910.74","891.94","1910.74","1 through 10","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","1829.79","1561.50","2617.12","88","840.11","1472.5","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1359.46","1201.30","1689.00","61","945","1482.71","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1718.92","1718.92","1718.92","1 through 10","945","1482.71","percent of total billed charges",""
"TIBIAL BEARING SZ 2 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","1910.74","1019.06","2344.84","74","945","1482.71","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1530.90","1160.93","1884.08","89","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","5253.92","5253.92","5253.92","1 through 10","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1934.88","58","","12181.47","12181.47","12181.47","1 through 10","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2085.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.85","44.45","","1910.74","891.94","1910.74","1 through 10","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","1829.79","1561.50","2617.12","88","1482.85","2599.08","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1359.46","1201.30","1689.00","61","1668","2617.09","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1718.92","1718.92","1718.92","1 through 10","1668","2617.09","percent of total billed charges",""
"TIBIAL BEARING SZ 6 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","1910.74","1019.06","2344.84","74","1668","2617.09","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","AETNA [1001]","HB CH AETNA HMO / PPO","346.86","58.3","","464.71","67.87","1012.10","221","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.86","58.3","","293.04","293.04","293.04","11","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","315.33","53","","983.89","983.89","983.89","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","345.08","58","","677.18","677.18","677.18","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","371.85","62.5","","46.58","46.58","46.58","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","434.32","73","","747.15","747.15","747.15","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.46","44.45","","1141.67","481.21","1141.67","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.46","44.45","","76.54","76.54","76.54","1 through 10","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.96","446.22","WELLPOINT [1015]","HB CH WELLPOINT","463.53","77.91","","273.64","94.28","1367.51","138","264.46","463.53","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.96","446.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.81","59.3","","720.78","230.14","2010.94","427","297.48","466.75","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.96","446.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","352.81","59.3","","344.45","344.45","344.45","1 through 10","297.48","466.75","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.96","446.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","466.75","78.45","","1120.13","1120.13","1120.13","1 through 10","297.48","466.75","percent of total billed charges",""
"TIBIAL ENDCAP 5MM EXTENDED TIP NAIL EX TI T40 STARDRIVE","SUP-ITM-10036798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.96","446.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","466.75","78.45","","456.17","105.33","1284.66","242","297.48","466.75","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","AETNA [1001]","HB CH AETNA HMO / PPO","284.09","58.3","","464.71","67.87","1012.10","221","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.09","58.3","","293.04","293.04","293.04","11","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.26","53","","983.89","983.89","983.89","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","282.63","58","","677.18","677.18","677.18","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","304.56","62.5","","46.58","46.58","46.58","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.72","73","","747.15","747.15","747.15","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.60","44.45","","1141.67","481.21","1141.67","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.60","44.45","","76.54","76.54","76.54","1 through 10","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","both","","","487.29","365.47","WELLPOINT [1015]","HB CH WELLPOINT","379.65","77.91","","273.64","94.28","1367.51","138","216.6","379.65","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.96","59.3","","720.78","230.14","2010.94","427","243.65","382.28","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","288.96","59.3","","344.45","344.45","344.45","1 through 10","243.65","382.28","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","382.28","78.45","","1120.13","1120.13","1120.13","1 through 10","243.65","382.28","percent of total billed charges",""
"TIBIAL ENDCAP 5MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","487.29","365.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.28","78.45","","456.17","105.33","1284.66","242","243.65","382.28","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","AETNA [1001]","HB CH AETNA HMO / PPO","1995.75","58.3","","464.71","67.87","1012.10","221","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1995.75","58.3","","293.04","293.04","293.04","11","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1814.32","53","","983.89","983.89","983.89","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1985.48","58","","677.18","677.18","677.18","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2139.53","62.5","","46.58","46.58","46.58","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2498.97","73","","747.15","747.15","747.15","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.63","44.45","","1141.67","481.21","1141.67","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.63","44.45","","76.54","76.54","76.54","1 through 10","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.24","2567.43","WELLPOINT [1015]","HB CH WELLPOINT","2667.05","77.91","","273.64","94.28","1367.51","138","1521.63","2667.05","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.24","2567.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2029.98","59.3","","720.78","230.14","2010.94","427","1711.62","2685.53","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.24","2567.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2029.98","59.3","","344.45","344.45","344.45","1 through 10","1711.62","2685.53","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.24","2567.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2685.53","78.45","","1120.13","1120.13","1120.13","1 through 10","1711.62","2685.53","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.24","2567.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2685.53","78.45","","456.17","105.33","1284.66","242","1711.62","2685.53","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","AETNA [1001]","HB CH AETNA HMO / PPO","2038.46","58.3","","464.71","67.87","1012.10","221","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2038.46","58.3","","293.04","293.04","293.04","11","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1853.15","53","","983.89","983.89","983.89","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2027.97","58","","677.18","677.18","677.18","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2185.31","62.5","","46.58","46.58","46.58","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2552.45","73","","747.15","747.15","747.15","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1554.19","44.45","","1141.67","481.21","1141.67","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1554.19","44.45","","76.54","76.54","76.54","1 through 10","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.50","2622.37","WELLPOINT [1015]","HB CH WELLPOINT","2724.12","77.91","","273.64","94.28","1367.51","138","1554.19","2724.12","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.50","2622.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2073.42","59.3","","720.78","230.14","2010.94","427","1748.25","2743","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.50","2622.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2073.42","59.3","","344.45","344.45","344.45","1 through 10","1748.25","2743","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.50","2622.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2743.00","78.45","","1120.13","1120.13","1120.13","1 through 10","1748.25","2743","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.50","2622.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2743.00","78.45","","456.17","105.33","1284.66","242","1748.25","2743","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","AETNA [1001]","HB CH AETNA HMO / PPO","1830.94","58.3","","1530.90","1160.93","1884.08","89","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1664.49","53","","5253.92","5253.92","5253.92","1 through 10","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1821.52","58","","12181.47","12181.47","12181.47","1 through 10","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1962.84","62.5","","1350.68","1350.68","1350.68","1 through 10","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1395.97","44.45","","1910.74","891.94","1910.74","1 through 10","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","WELLPOINT [1015]","HB CH WELLPOINT","2446.80","77.91","","1829.79","1561.50","2617.12","88","1395.97","2446.8","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1359.46","1201.30","1689.00","61","1570.28","2463.76","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1718.92","1718.92","1718.92","1 through 10","1570.28","2463.76","percent of total billed charges",""
"TIBIAL INSERT 10MM 6-9 TIB EF PERSONA VIVACIT-E CONSTRAINED POSTERIOR STABILIZED LT FEMORAL","SUP-ITM-10120466","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2463.76","78.45","","1910.74","1019.06","2344.84","74","1570.28","2463.76","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1530.90","1160.93","1884.08","89","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","5253.92","5253.92","5253.92","1 through 10","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","828.24","58","","12181.47","12181.47","12181.47","1 through 10","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","892.50","62.5","","1350.68","1350.68","1350.68","1 through 10","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","1910.74","891.94","1910.74","1 through 10","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","1829.79","1561.50","2617.12","88","634.75","1112.55","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1359.46","1201.30","1689.00","61","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","846.80","59.3","","1718.92","1718.92","1718.92","1 through 10","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 2.5X80MM SIGMA CROSS LINKED POLYETHYLENE CURVED BEARING","SUP-ITM-10012837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","1910.74","1019.06","2344.84","74","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","AETNA [1001]","HB CH AETNA HMO / PPO","198.51","58.3","","1530.90","1160.93","1884.08","89","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.47","53","","5253.92","5253.92","5253.92","1 through 10","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","197.49","58","","12181.47","12181.47","12181.47","1 through 10","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","212.81","62.5","","1350.68","1350.68","1350.68","1 through 10","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.35","44.45","","1910.74","891.94","1910.74","1 through 10","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","WELLPOINT [1015]","HB CH WELLPOINT","265.28","77.91","","1829.79","1561.50","2617.12","88","151.35","265.28","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","340.50","255.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.92","59.3","","1359.46","1201.30","1689.00","61","170.25","267.12","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","340.50","255.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","201.92","59.3","","1718.92","1718.92","1718.92","1 through 10","170.25","267.12","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","340.50","255.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.12","78.45","","1910.74","1019.06","2344.84","74","170.25","267.12","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","AETNA [1001]","HB CH AETNA HMO / PPO","1951.62","58.3","","464.71","67.87","1012.10","221","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.62","58.3","","293.04","293.04","293.04","11","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1774.20","53","","983.89","983.89","983.89","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1941.58","58","","677.18","677.18","677.18","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2092.22","62.5","","46.58","46.58","46.58","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.71","73","","747.15","747.15","747.15","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.99","44.45","","1141.67","481.21","1141.67","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.99","44.45","","76.54","76.54","76.54","1 through 10","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","3347.55","2510.66","WELLPOINT [1015]","HB CH WELLPOINT","2608.08","77.91","","273.64","94.28","1367.51","138","1487.99","2608.08","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3347.55","2510.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","1985.10","59.3","","720.78","230.14","2010.94","427","1673.78","2626.15","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3347.55","2510.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1985.10","59.3","","344.45","344.45","344.45","1 through 10","1673.78","2626.15","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3347.55","2510.66","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2626.15","78.45","","1120.13","1120.13","1120.13","1 through 10","1673.78","2626.15","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3347.55","2510.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2626.15","78.45","","456.17","105.33","1284.66","242","1673.78","2626.15","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","AETNA [1001]","HB CH AETNA HMO / PPO","1918.04","58.3","","1530.90","1160.93","1884.08","89","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1743.67","53","","5253.92","5253.92","5253.92","1 through 10","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1908.17","58","","12181.47","12181.47","12181.47","1 through 10","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2056.22","62.5","","1350.68","1350.68","1350.68","1 through 10","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1462.38","44.45","","1910.74","891.94","1910.74","1 through 10","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.95","2467.46","WELLPOINT [1015]","HB CH WELLPOINT","2563.20","77.91","","1829.79","1561.50","2617.12","88","1462.38","2563.2","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.95","2467.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","1950.94","59.3","","1359.46","1201.30","1689.00","61","1644.98","2580.97","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.95","2467.46","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1950.94","59.3","","1718.92","1718.92","1718.92","1 through 10","1644.98","2580.97","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.95","2467.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2580.97","78.45","","1910.74","1019.06","2344.84","74","1644.98","2580.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","AETNA [1001]","HB CH AETNA HMO / PPO","2223.12","58.3","","464.71","67.87","1012.10","221","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2223.12","58.3","","293.04","293.04","293.04","11","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2021.02","53","","983.89","983.89","983.89","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2211.68","58","","677.18","677.18","677.18","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2383.28","62.5","","46.58","46.58","46.58","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2783.67","73","","747.15","747.15","747.15","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1694.99","44.45","","1141.67","481.21","1141.67","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1694.99","44.45","","76.54","76.54","76.54","1 through 10","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3813.24","2859.93","WELLPOINT [1015]","HB CH WELLPOINT","2970.90","77.91","","273.64","94.28","1367.51","138","1694.99","2970.9","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.24","2859.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2261.25","59.3","","720.78","230.14","2010.94","427","1906.62","2991.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.24","2859.93","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2261.25","59.3","","344.45","344.45","344.45","1 through 10","1906.62","2991.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.24","2859.93","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2991.49","78.45","","1120.13","1120.13","1120.13","1 through 10","1906.62","2991.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3813.24","2859.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2991.49","78.45","","456.17","105.33","1284.66","242","1906.62","2991.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","AETNA [1001]","HB CH AETNA HMO / PPO","1697.42","58.3","","464.71","67.87","1012.10","221","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1697.42","58.3","","293.04","293.04","293.04","11","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.11","53","","983.89","983.89","983.89","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1688.69","58","","677.18","677.18","677.18","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1819.71","62.5","","46.58","46.58","46.58","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2125.42","73","","747.15","747.15","747.15","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.18","44.45","","1141.67","481.21","1141.67","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.18","44.45","","76.54","76.54","76.54","1 through 10","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","WELLPOINT [1015]","HB CH WELLPOINT","2268.37","77.91","","273.64","94.28","1367.51","138","1294.18","2268.37","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1726.54","59.3","","720.78","230.14","2010.94","427","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1726.54","59.3","","344.45","344.45","344.45","1 through 10","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2284.10","78.45","","1120.13","1120.13","1120.13","1 through 10","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2284.10","78.45","","456.17","105.33","1284.66","242","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","AETNA [1001]","HB CH AETNA HMO / PPO","1788.02","58.3","","464.71","67.87","1012.10","221","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1788.02","58.3","","293.04","293.04","293.04","11","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1625.47","53","","983.89","983.89","983.89","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1778.82","58","","677.18","677.18","677.18","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1916.83","62.5","","46.58","46.58","46.58","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2238.86","73","","747.15","747.15","747.15","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1363.25","44.45","","1141.67","481.21","1141.67","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1363.25","44.45","","76.54","76.54","76.54","1 through 10","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.93","2300.20","WELLPOINT [1015]","HB CH WELLPOINT","2389.45","77.91","","273.64","94.28","1367.51","138","1363.25","2389.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.93","2300.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1818.69","59.3","","720.78","230.14","2010.94","427","1533.47","2406.01","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.93","2300.20","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1818.69","59.3","","344.45","344.45","344.45","1 through 10","1533.47","2406.01","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.93","2300.20","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2406.01","78.45","","1120.13","1120.13","1120.13","1 through 10","1533.47","2406.01","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.93","2300.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2406.01","78.45","","456.17","105.33","1284.66","242","1533.47","2406.01","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","AETNA [1001]","HB CH AETNA HMO / PPO","2252.45","58.3","","464.71","67.87","1012.10","221","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2252.45","58.3","","293.04","293.04","293.04","11","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2047.68","53","","983.89","983.89","983.89","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2240.86","58","","677.18","677.18","677.18","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2414.72","62.5","","46.58","46.58","46.58","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2820.39","73","","747.15","747.15","747.15","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1717.35","44.45","","1141.67","481.21","1141.67","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1717.35","44.45","","76.54","76.54","76.54","1 through 10","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","WELLPOINT [1015]","HB CH WELLPOINT","3010.09","77.91","","273.64","94.28","1367.51","138","1717.35","3010.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2291.09","59.3","","720.78","230.14","2010.94","427","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2291.09","59.3","","344.45","344.45","344.45","1 through 10","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","3030.95","78.45","","1120.13","1120.13","1120.13","1 through 10","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3030.95","78.45","","456.17","105.33","1284.66","242","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","AETNA [1001]","HB CH AETNA HMO / PPO","1716.84","58.3","","464.71","67.87","1012.10","221","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1716.84","58.3","","293.04","293.04","293.04","11","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1560.76","53","","983.89","983.89","983.89","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1708.00","58","","677.18","677.18","677.18","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1840.52","62.5","","46.58","46.58","46.58","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2149.73","73","","747.15","747.15","747.15","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1308.98","44.45","","1141.67","481.21","1141.67","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1308.98","44.45","","76.54","76.54","76.54","1 through 10","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","WELLPOINT [1015]","HB CH WELLPOINT","2294.32","77.91","","273.64","94.28","1367.51","138","1308.98","2294.32","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1746.28","59.3","","720.78","230.14","2010.94","427","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1746.28","59.3","","344.45","344.45","344.45","1 through 10","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2310.22","78.45","","1120.13","1120.13","1120.13","1 through 10","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2310.22","78.45","","456.17","105.33","1284.66","242","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","AETNA [1001]","HB CH AETNA HMO / PPO","1807.43","58.3","","464.71","67.87","1012.10","221","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1807.43","58.3","","293.04","293.04","293.04","11","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1643.12","53","","983.89","983.89","983.89","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1798.13","58","","677.18","677.18","677.18","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1937.64","62.5","","46.58","46.58","46.58","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2263.17","73","","747.15","747.15","747.15","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.05","44.45","","1141.67","481.21","1141.67","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.05","44.45","","76.54","76.54","76.54","1 through 10","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3100.23","2325.17","WELLPOINT [1015]","HB CH WELLPOINT","2415.39","77.91","","273.64","94.28","1367.51","138","1378.05","2415.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3100.23","2325.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","1838.44","59.3","","720.78","230.14","2010.94","427","1550.12","2432.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3100.23","2325.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1838.44","59.3","","344.45","344.45","344.45","1 through 10","1550.12","2432.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3100.23","2325.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2432.13","78.45","","1120.13","1120.13","1120.13","1 through 10","1550.12","2432.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3100.23","2325.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2432.13","78.45","","456.17","105.33","1284.66","242","1550.12","2432.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","AETNA [1001]","HB CH AETNA HMO / PPO","1905.15","58.3","","464.71","67.87","1012.10","221","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1905.15","58.3","","293.04","293.04","293.04","11","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1731.96","53","","983.89","983.89","983.89","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1895.35","58","","677.18","677.18","677.18","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2042.40","62.5","","46.58","46.58","46.58","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2385.52","73","","747.15","747.15","747.15","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1452.55","44.45","","1141.67","481.21","1141.67","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1452.55","44.45","","76.54","76.54","76.54","1 through 10","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.84","2450.88","WELLPOINT [1015]","HB CH WELLPOINT","2545.97","77.91","","273.64","94.28","1367.51","138","1452.55","2545.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.84","2450.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","1937.83","59.3","","720.78","230.14","2010.94","427","1633.92","2563.62","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.84","2450.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1937.83","59.3","","344.45","344.45","344.45","1 through 10","1633.92","2563.62","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.84","2450.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2563.62","78.45","","1120.13","1120.13","1120.13","1 through 10","1633.92","2563.62","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.84","2450.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2563.62","78.45","","456.17","105.33","1284.66","242","1633.92","2563.62","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","AETNA [1001]","HB CH AETNA HMO / PPO","1988.25","58.3","","464.71","67.87","1012.10","221","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1988.25","58.3","","293.04","293.04","293.04","11","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1807.50","53","","983.89","983.89","983.89","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1978.01","58","","677.18","677.18","677.18","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2131.48","62.5","","46.58","46.58","46.58","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2489.57","73","","747.15","747.15","747.15","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.91","44.45","","1141.67","481.21","1141.67","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.91","44.45","","76.54","76.54","76.54","1 through 10","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.37","2557.78","WELLPOINT [1015]","HB CH WELLPOINT","2657.02","77.91","","273.64","94.28","1367.51","138","1515.91","2657.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.37","2557.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2022.35","59.3","","720.78","230.14","2010.94","427","1705.19","2675.44","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.37","2557.78","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2022.35","59.3","","344.45","344.45","344.45","1 through 10","1705.19","2675.44","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.37","2557.78","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2675.44","78.45","","1120.13","1120.13","1120.13","1 through 10","1705.19","2675.44","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.37","2557.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2675.44","78.45","","456.17","105.33","1284.66","242","1705.19","2675.44","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","AETNA [1001]","HB CH AETNA HMO / PPO","2021.25","58.3","","464.71","67.87","1012.10","221","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2021.25","58.3","","293.04","293.04","293.04","11","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1837.50","53","","983.89","983.89","983.89","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2010.85","58","","677.18","677.18","677.18","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2166.86","62.5","","46.58","46.58","46.58","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2530.90","73","","747.15","747.15","747.15","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1541.07","44.45","","1141.67","481.21","1141.67","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1541.07","44.45","","76.54","76.54","76.54","1 through 10","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","WELLPOINT [1015]","HB CH WELLPOINT","2701.12","77.91","","273.64","94.28","1367.51","138","1541.07","2701.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","CIGNA [1006]","HB CH CIGNA HMO / PPO","2055.92","59.3","","720.78","230.14","2010.94","427","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2055.92","59.3","","344.45","344.45","344.45","1 through 10","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2719.85","78.45","","1120.13","1120.13","1120.13","1 through 10","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2719.85","78.45","","456.17","105.33","1284.66","242","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","AETNA [1001]","HB CH AETNA HMO / PPO","1996.27","58.3","","464.71","67.87","1012.10","221","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1996.27","58.3","","293.04","293.04","293.04","11","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1814.79","53","","983.89","983.89","983.89","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1986.00","58","","677.18","677.18","677.18","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2140.09","62.5","","46.58","46.58","46.58","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2499.62","73","","747.15","747.15","747.15","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.03","44.45","","1141.67","481.21","1141.67","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.03","44.45","","76.54","76.54","76.54","1 through 10","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","WELLPOINT [1015]","HB CH WELLPOINT","2667.75","77.91","","273.64","94.28","1367.51","138","1522.03","2667.75","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2030.52","59.3","","720.78","230.14","2010.94","427","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2030.52","59.3","","344.45","344.45","344.45","1 through 10","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2686.24","78.45","","1120.13","1120.13","1120.13","1 through 10","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2686.24","78.45","","456.17","105.33","1284.66","242","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","AETNA [1001]","HB CH AETNA HMO / PPO","2753.79","58.3","","1530.90","1160.93","1884.08","89","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2503.44","53","","5253.92","5253.92","5253.92","1 through 10","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2739.62","58","","12181.47","12181.47","12181.47","1 through 10","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2952.18","62.5","","1350.68","1350.68","1350.68","1 through 10","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2099.59","44.45","","1910.74","891.94","1910.74","1 through 10","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","both","","","4723.48","3542.61","WELLPOINT [1015]","HB CH WELLPOINT","3680.06","77.91","","1829.79","1561.50","2617.12","88","2099.59","3680.06","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4723.48","3542.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","2801.02","59.3","","1359.46","1201.30","1689.00","61","2361.74","3705.57","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4723.48","3542.61","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2801.02","59.3","","1718.92","1718.92","1718.92","1 through 10","2361.74","3705.57","percent of total billed charges",""
"TIBIAL PLATE L 84MM 5 HOLE IMAL LEFT","SUP-ITM-10186914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4723.48","3542.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3705.57","78.45","","1910.74","1019.06","2344.84","74","2361.74","3705.57","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","AETNA [1001]","HB CH AETNA HMO / PPO","1626.57","58.3","","1530.90","1160.93","1884.08","89","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1478.70","53","","5253.92","5253.92","5253.92","1 through 10","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1618.20","58","","12181.47","12181.47","12181.47","1 through 10","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1743.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1240.16","44.45","","1910.74","891.94","1910.74","1 through 10","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","WELLPOINT [1015]","HB CH WELLPOINT","2173.69","77.91","","1829.79","1561.50","2617.12","88","1240.16","2173.69","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1654.47","59.3","","1359.46","1201.30","1689.00","61","1395","2188.76","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1654.47","59.3","","1718.92","1718.92","1718.92","1 through 10","1395","2188.76","percent of total billed charges",""
"TIBIAL TRAY SZ 5 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2188.76","78.45","","1910.74","1019.06","2344.84","74","1395","2188.76","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","AETNA [1001]","HB CH AETNA HMO / PPO","988.19","58.3","","464.71","67.87","1012.10","221","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","988.19","58.3","","293.04","293.04","293.04","11","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","898.35","53","","983.89","983.89","983.89","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","983.10","58","","677.18","677.18","677.18","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1059.38","62.5","","46.58","46.58","46.58","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1237.35","73","","747.15","747.15","747.15","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.43","44.45","","1141.67","481.21","1141.67","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.43","44.45","","76.54","76.54","76.54","1 through 10","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","WELLPOINT [1015]","HB CH WELLPOINT","1320.57","77.91","","273.64","94.28","1367.51","138","753.43","1320.57","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.14","59.3","","720.78","230.14","2010.94","427","847.5","1329.73","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1005.14","59.3","","344.45","344.45","344.45","1 through 10","847.5","1329.73","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","1120.13","1120.13","1120.13","1 through 10","847.5","1329.73","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","456.17","105.33","1284.66","242","847.5","1329.73","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","732.00","549.00","AETNA [1001]","HB CH AETNA HMO / PPO","426.76","58.3","","2190.90","412.50","9264.59","16","325.37","570.3","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","732.00","549.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","424.56","58","","1903.20","1903.20","3826.66","1 through 10","325.37","570.3","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","732.00","549.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","457.50","62.5","","2186.25","2186.25","2186.25","32","325.37","570.3","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","732.00","549.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","534.36","73","","5556.60","5556.60","5556.60","1 through 10","325.37","570.3","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","732.00","549.00","WELLPOINT [1015]","HB CH WELLPOINT","570.30","77.91","","1955.15","885.83","3150.40","26","325.37","570.3","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","732.00","549.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","434.08","59.3","","831.03","253.22","2394.88","18","366","574.25","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","732.00","549.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","574.25","78.45","","2481.69","1563.74","8149.28","1 through 10","366","574.25","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","AETNA [1001]","HB CH AETNA HMO / PPO","18.58","58.3","","464.71","67.87","1012.10","221","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","18.58","58.3","","293.04","293.04","293.04","11","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","16.89","53","","983.89","983.89","983.89","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","18.48","58","","677.18","677.18","677.18","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","19.92","62.5","","46.58","46.58","46.58","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","23.27","73","","747.15","747.15","747.15","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.17","44.45","","1141.67","481.21","1141.67","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.17","44.45","","76.54","76.54","76.54","1 through 10","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","31.87","23.90","WELLPOINT [1015]","HB CH WELLPOINT","24.83","77.91","","273.64","94.28","1367.51","138","14.17","24.83","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","31.87","23.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","18.90","59.3","","720.78","230.14","2010.94","427","15.94","25","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","31.87","23.90","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","18.90","59.3","","344.45","344.45","344.45","1 through 10","15.94","25","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","31.87","23.90","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","25.00","78.45","","1120.13","1120.13","1120.13","1 through 10","15.94","25","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","31.87","23.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.00","78.45","","456.17","105.33","1284.66","242","15.94","25","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","both","","","1334.48","1000.86","AETNA [1001]","HB CH AETNA HMO / PPO","778.00","58.3","","416.75","416.75","416.75","1 through 10","593.18","1039.69","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1334.48","1000.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.35","59.3","","7893.60","423.68","7893.60","1 through 10","667.24","1046.9","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1334.48","1000.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1046.90","78.45","","555.84","329.40","555.84","1 through 10","667.24","1046.9","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","both","","","3768.09","2826.07","AETNA [1001]","HB CH AETNA HMO / PPO","2196.80","58.3","","416.75","416.75","416.75","1 through 10","1674.92","2935.72","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3768.09","2826.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","2234.48","59.3","","7893.60","423.68","7893.60","1 through 10","1884.05","2956.07","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3768.09","2826.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2956.07","78.45","","555.84","329.40","555.84","1 through 10","1884.05","2956.07","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","both","","","6431.45","4823.59","AETNA [1001]","HB CH AETNA HMO / PPO","3749.54","58.3","","416.75","416.75","416.75","1 through 10","2858.78","5010.74","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6431.45","4823.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","3813.85","59.3","","7893.60","423.68","7893.60","1 through 10","3215.73","5045.47","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6431.45","4823.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5045.47","78.45","","555.84","329.40","555.84","1 through 10","3215.73","5045.47","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","272.73","272.73","272.73","1 through 10","114.16","687.33","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","281.87","281.87","281.87","1 through 10","218.3","437.51","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","369.79","219.14","369.79","1 through 10","218.3","437.51","percent of total billed charges",""
"Tissue Exam Koh Skin/Hair/Nail","PX-30001197","CDM","87220","CPT","0306","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.82","1 through 10","4.18","40.85","percent of total billed charges",""
"Tissue Exam Koh Skin/Hair/Nail","PX-30001197","CDM","87220","CPT","0306","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.50","59.3","","24.61","24.61","24.61","1 through 10","4.4","33.73","percent of total billed charges",""
"Tissue Exam Koh Skin/Hair/Nail","PX-30001197","CDM","87220","CPT","0306","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.73","78.45","","32.29","32.29","32.29","1 through 10","4.4","33.73","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","AETNA [1001]","HB CH AETNA HMO / PPO","2080.77","58.3","","2190.90","412.50","9264.59","16","1586.46","2780.67","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2070.07","58","","1903.20","1903.20","3826.66","1 through 10","1586.46","2780.67","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2230.68","62.5","","2186.25","2186.25","2186.25","32","1586.46","2780.67","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2605.43","73","","5556.60","5556.60","5556.60","1 through 10","1586.46","2780.67","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","WELLPOINT [1015]","HB CH WELLPOINT","2780.67","77.91","","1955.15","885.83","3150.40","26","1586.46","2780.67","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3569.08","2676.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2116.46","59.3","","831.03","253.22","2394.88","18","1784.54","2799.94","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3569.08","2676.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2799.94","78.45","","2481.69","1563.74","8149.28","1 through 10","1784.54","2799.94","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","AETNA [1001]","HB CH AETNA HMO / PPO","2264.71","58.3","","2190.90","412.50","9264.59","16","1726.7","3026.48","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2253.06","58","","1903.20","1903.20","3826.66","1 through 10","1726.7","3026.48","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2427.86","62.5","","2186.25","2186.25","2186.25","32","1726.7","3026.48","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2835.74","73","","5556.60","5556.60","5556.60","1 through 10","1726.7","3026.48","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","WELLPOINT [1015]","HB CH WELLPOINT","3026.48","77.91","","1955.15","885.83","3150.40","26","1726.7","3026.48","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.56","59.3","","831.03","253.22","2394.88","18","1942.29","3047.45","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.45","78.45","","2481.69","1563.74","8149.28","1 through 10","1942.29","3047.45","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","AETNA [1001]","HB CH AETNA HMO / PPO","2274.50","58.3","","2190.90","412.50","9264.59","16","1734.16","3039.57","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2262.80","58","","1903.20","1903.20","3826.66","1 through 10","1734.16","3039.57","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2438.36","62.5","","2186.25","2186.25","2186.25","32","1734.16","3039.57","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2848.01","73","","5556.60","5556.60","5556.60","1 through 10","1734.16","3039.57","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","WELLPOINT [1015]","HB CH WELLPOINT","3039.57","77.91","","1955.15","885.83","3150.40","26","1734.16","3039.57","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3901.38","2926.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","2313.52","59.3","","831.03","253.22","2394.88","18","1950.69","3060.63","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3901.38","2926.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3060.63","78.45","","2481.69","1563.74","8149.28","1 through 10","1950.69","3060.63","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","AETNA [1001]","HB CH AETNA HMO / PPO","2500.53","58.3","","2190.90","412.50","9264.59","16","1906.5","3341.62","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2487.67","58","","1903.20","1903.20","3826.66","1 through 10","1906.5","3341.62","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2680.68","62.5","","2186.25","2186.25","2186.25","32","1906.5","3341.62","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3131.03","73","","5556.60","5556.60","5556.60","1 through 10","1906.5","3341.62","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","WELLPOINT [1015]","HB CH WELLPOINT","3341.62","77.91","","1955.15","885.83","3150.40","26","1906.5","3341.62","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4289.08","3216.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2543.42","59.3","","831.03","253.22","2394.88","18","2144.54","3364.78","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4289.08","3216.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3364.78","78.45","","2481.69","1563.74","8149.28","1 through 10","2144.54","3364.78","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","AETNA [1001]","HB CH AETNA HMO / PPO","2264.71","58.3","","2190.90","412.50","9264.59","16","1726.7","3026.48","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2253.06","58","","1903.20","1903.20","3826.66","1 through 10","1726.7","3026.48","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2427.86","62.5","","2186.25","2186.25","2186.25","32","1726.7","3026.48","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2835.74","73","","5556.60","5556.60","5556.60","1 through 10","1726.7","3026.48","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","WELLPOINT [1015]","HB CH WELLPOINT","3026.48","77.91","","1955.15","885.83","3150.40","26","1726.7","3026.48","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.56","59.3","","831.03","253.22","2394.88","18","1942.29","3047.45","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.45","78.45","","2481.69","1563.74","8149.28","1 through 10","1942.29","3047.45","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","70.66","72.1","","71.63","71.63","71.63","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","WELLPOINT [1015]","HB CH WELLPOINT","76.35","77.91","","74.82","74.82","74.82","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","56.55","57.7","","57.29","57.29","57.29","1 through 10","23.48","76.88","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","60.14","60.14","60.14","1 through 10","23.48","76.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","AETNA [1001]","HB CH AETNA HMO / PPO","4022.70","58.3","","2190.90","412.50","9264.59","16","3067.05","5375.79","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4002.00","58","","1903.20","1903.20","3826.66","1 through 10","3067.05","5375.79","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4312.50","62.5","","2186.25","2186.25","2186.25","32","3067.05","5375.79","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5037.00","73","","5556.60","5556.60","5556.60","1 through 10","3067.05","5375.79","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","WELLPOINT [1015]","HB CH WELLPOINT","5375.79","77.91","","1955.15","885.83","3150.40","26","3067.05","5375.79","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4091.70","59.3","","831.03","253.22","2394.88","18","3450","5413.05","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5413.05","78.45","","2481.69","1563.74","8149.28","1 through 10","3450","5413.05","percent of total billed charges",""
"Tonsil And Adenoid Procedures,MODERATE","097","DRG","","","","","","","","inpatient","","","32973.57","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9024.4956","","Fee schedule rate ($13,738.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9024.4956","13738.02","13738.02","1 through 10","4909.89","22667.53","case rate",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","AETNA [1001]","HB CH AETNA HMO / PPO","423.26","58.3","","464.71","67.87","1012.10","221","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","423.26","58.3","","293.04","293.04","293.04","11","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","384.78","53","","983.89","983.89","983.89","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","421.08","58","","677.18","677.18","677.18","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","453.75","62.5","","46.58","46.58","46.58","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","529.98","73","","747.15","747.15","747.15","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.71","44.45","","1141.67","481.21","1141.67","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.71","44.45","","76.54","76.54","76.54","1 through 10","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.00","544.50","WELLPOINT [1015]","HB CH WELLPOINT","565.63","77.91","","273.64","94.28","1367.51","138","322.71","565.63","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.00","544.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","430.52","59.3","","720.78","230.14","2010.94","427","363","569.55","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.00","544.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","430.52","59.3","","344.45","344.45","344.45","1 through 10","363","569.55","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.00","544.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","569.55","78.45","","1120.13","1120.13","1120.13","1 through 10","363","569.55","percent of total billed charges",""
"TOP HAT SCREW BONE","SUP-ITM-10194609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","569.55","78.45","","456.17","105.33","1284.66","242","363","569.55","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","1 through 10","11.68","95.95","percent of total billed charges",""
"Total Abdominal Hysterect W/WO Rmvl Tube Ovary","PX-76001381","CDM","58150","CPT","0761","RC","","","","outpatient","","","6381.00","4785.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1712.89","","Case rate ($1,712.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2476.84","2476.84","2476.84","1 through 10","1712.89","5005.89","other","ASC "
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","23.63","147.25","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","265.47","88.49","265.47","1 through 10","18.62","121.6","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","67.80","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","116.09","116.09","1 through 10","18.62","121.6","percent of total billed charges",""
"Toxic Effects Of Non-Medicinal Substances,MAJOR","816","DRG","","","","","","","","inpatient","","","60057.20","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","21373.63","","Fee schedule rate ($21,373.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42578.70","42578.70","42578.70","1 through 10","4963.81","28213.5","case rate",""
"Toxic Effects Of Non-Medicinal Substances,MODERATE","816","DRG","","","","","","","","inpatient","","","8344.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14149.26","","Standard inlier is a Case rate ($14,149.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,162, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,008.43) for the length of stay and the standard reimbursement.","14149.25","14149.25","14149.25","1 through 10","4963.81","28213.5","case rate",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","14.1","114.95","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","118.00","118.00","118.00","1 through 10","14.1","114.95","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","14.84","94.92","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","90.72","1 through 10","14.84","94.92","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","14.12","114.95","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","114.95","95","","118.00","118.00","118.00","1 through 10","14.12","114.95","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","14.84","94.92","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","53.76","53.76","90.72","1 through 10","14.84","94.92","percent of total billed charges",""
"Tpmt and Nudt15 Genotype","PX-31000921","CDM","0034U","CPT","0310","RC","","","","both","","","1460.00","1095.00","AETNA [1001]","HB CH AETNA HMO / PPO","851.18","58.3","","805.14","805.14","805.14","1 through 10","456.85","1813.4","percent of total billed charges",""
"Tpmt Nudt15 Gene Analysis Common Variants","PX-31001014","CDM","0034U","CPT","0310","RC","","","","both","","","1460.00","1095.00","AETNA [1001]","HB CH AETNA HMO / PPO","851.18","58.3","","805.14","805.14","805.14","1 through 10","456.85","1813.4","percent of total billed charges",""
"Trachelorrhaphy Vaginal Approach","PX-76001375","CDM","57720","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","2422.52","2422.52","2422.52","1 through 10","1850","3628.31","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","both","","","4610.00","3457.50","AETNA [1001]","HB CH AETNA HMO / PPO","2687.63","58.3","","3339.63","3339.63","3339.63","1 through 10","1548.96","3591.65","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2561.33","1280.67","2561.33","1 through 10","1548.96","4472.66","other","ASC "
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","59.54","59.54","59.54","1 through 10","12.5","102.6","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","61.53","61.53","61.53","1 through 10","13.17","84.73","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","534.70","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","487.53","487.53","487.53","1 through 10","415.61","1489.48","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","MEDICARE [2001]","HB NWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","519.18","519.18","947.58","16","415.61","1489.48","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($270). Procedure 2, Per diem ($135). Procedures 3 - 9999, Per diem ($67.50).","581.76","581.76","581.76","1 through 10","415.61","1489.48","per diem",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","682.55","73","","498.01","498.01","498.01","1 through 10","415.61","1489.48","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","508.74","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","928.62","928.62","928.62","1 through 10","415.61","1489.48","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","508.74","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","508.80","508.80","508.80","1 through 10","415.61","1489.48","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","WELLPOINT [1015]","HB CH WELLPOINT","728.46","77.91","","715.93","715.93","715.93","1 through 10","415.61","1489.48","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","935.00","701.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","632.28","619.15","632.28","1 through 10","437.87","1334.96","other","ASC "
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","935.00","701.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","633.16","620.02","633.16","1 through 10","437.87","1334.96","other","ASC "
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","935.00","701.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","733.51","78.45","","414.14","414.14","414.14","1 through 10","437.87","1334.96","percent of total billed charges",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","40868.86","30651.64","MEDICARE [2001]","HB NWH MEDICARE","7609.53","","Case rate ($7,609.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,109.49, add-ons for qualifying new technology services are included. If operating cost exceeds $52,251.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,470.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,080.65. The transfer operating threshold is the transfer adjustment factor * $7,109.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $528.88. The transfer capital threshold is the transfer adjustment factor * $528.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7650.02","7636.30","7650.02","1 through 10","6782.33","7899.3332","other","Inpatient DRG"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","800.00","600.00","AETNA [1001]","HB CH AETNA HMO / PPO","466.40","58.3","","441.13","441.13","441.13","1 through 10","145.39","623.28","percent of total billed charges",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","800.00","600.00","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.48","157.48","157.48","1 through 10","145.39","623.28","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","800.00","600.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","145.39","623.28","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","800.00","600.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","141.39","449.94","13","145.39","623.28","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","800.00","600.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","141.40","149.98","1 through 10","145.39","623.28","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB CH AETNA HMO / PPO","325.31","58.3","","307.88","307.88","307.88","1 through 10","145.39","434.74","percent of total billed charges",""
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","158.12","158.12","158.12","1 through 10","145.39","434.74","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","558.00","418.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","145.39","434.74","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","558.00","418.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","149.98","149.98","1 through 10","145.39","434.74","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","141.40","149.98","1 through 10","145.39","434.74","other","OPPS APC"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","31218.06","23413.54","MEDICARE [2001]","HB NWH MEDICARE","14784.67","","Case rate ($14,784.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,813.11, add-ons for qualifying new technology services are included. If operating cost exceeds $58,955.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,969.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,757.11. The transfer operating threshold is the transfer adjustment factor * $13,813.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,027.56. The transfer capital threshold is the transfer adjustment factor * $1,027.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5647.41","5647.41","5647.41","1 through 10","13177.49","15303.2275","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","31563.36","23672.52","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","14023.53","","Case rate ($14,023.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,101.99, add-ons for qualifying new technology services are included. If operating cost exceeds $58,244.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,916.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,048.86. The transfer operating threshold is the transfer adjustment factor * $13,101.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.66. The transfer capital threshold is the transfer adjustment factor * $974.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12811.88","12811.88","12811.88","1 through 10","12499.09","15111.11","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","31563.36","23672.52","MEDICARE [2001]","HB NWH MEDICARE","14023.53","","Case rate ($14,023.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,101.99, add-ons for qualifying new technology services are included. If operating cost exceeds $58,244.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,916.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,048.86. The transfer operating threshold is the transfer adjustment factor * $13,101.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.66. The transfer capital threshold is the transfer adjustment factor * $974.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14179.77","728.09","14205.26","1 through 10","12499.09","15111.11","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","22590.30","16942.72","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","8174.23","","Case rate ($7,936.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,152.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,294.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,329.68. The transfer operating threshold is the transfer adjustment factor * $8,152.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.47. The transfer capital threshold is the transfer adjustment factor * $606.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8309.33","8309.33","8309.33","1 through 10","7777.43","9134.4693","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","22590.30","16942.72","MEDICARE [2001]","HB NWH MEDICARE","7936.15","","Case rate ($7,936.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,152.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,294.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,329.68. The transfer operating threshold is the transfer adjustment factor * $8,152.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.47. The transfer capital threshold is the transfer adjustment factor * $606.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8815.94","978.30","8831.80","13","7777.43","9134.4693","other","Inpatient Replacement Plans DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","22590.30","16942.72","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7777.43","","Case rate ($7,936.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,152.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,294.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,548.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,329.68. The transfer operating threshold is the transfer adjustment factor * $8,152.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.47. The transfer capital threshold is the transfer adjustment factor * $606.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7896.35","7896.35","7896.35","1 through 10","7777.43","9134.4693","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","28084.77","21063.58","MEDICARE [2001]","HB NWH MEDICARE","12409.78","","Case rate ($12,409.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,594.30, add-ons for qualifying new technology services are included. If operating cost exceeds $56,736.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,804.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $11,547.28. The transfer operating threshold is the transfer adjustment factor * $11,594.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.50. The transfer capital threshold is the transfer adjustment factor * $862.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8345.84","905.99","12518.14","1 through 10","11060.76","12970.4124","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","55051.90","41288.92","MEDICARE [2001]","HB NWH MEDICARE","21642.59","","Case rate ($21,642.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,220.38, add-ons for qualifying new technology services are included. If operating cost exceeds $65,362.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,446.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $20,138.38. The transfer operating threshold is the transfer adjustment factor * $20,220.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.20. The transfer capital threshold is the transfer adjustment factor * $1,504.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21627.09","21627.09","21665.97","1 through 10","19289.91","22408.474","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","55051.90","41288.92","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","19289.91","","Case rate ($19,683.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,220.38, add-ons for qualifying new technology services are included. If operating cost exceeds $65,362.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,446.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,179.38. The transfer operating threshold is the transfer adjustment factor * $20,220.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.20. The transfer capital threshold is the transfer adjustment factor * $1,504.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8408.70","8408.70","8408.70","1 through 10","19289.91","22408.474","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour Without Cc/McC","087","MS-DRG","","","","","","","","inpatient","","","15766.19","11824.64","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7766.39","","Case rate ($7,924.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,141.01, add-ons for qualifying new technology services are included. If operating cost exceeds $53,283.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,547.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,319.28. The transfer operating threshold is the transfer adjustment factor * $8,141.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $605.61. The transfer capital threshold is the transfer adjustment factor * $605.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7543.06","7543.06","7543.06","1 through 10","7766.39","8741.876","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","30432.25","22824.19","MEDICARE [2001]","HB NWH MEDICARE","13296.67","","Case rate ($13,296.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,422.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,565.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,866.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,372.53. The transfer operating threshold is the transfer adjustment factor * $12,422.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.14. The transfer capital threshold is the transfer adjustment factor * $924.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13294.07","13294.07","13294.07","1 through 10","11851.24","14327.89","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","30432.25","22824.19","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","11851.24","","Case rate ($12,093.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,422.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,565.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,866.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,168.97. The transfer operating threshold is the transfer adjustment factor * $12,422.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.14. The transfer capital threshold is the transfer adjustment factor * $924.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11891.17","11891.17","11891.17","1 through 10","11851.24","14327.89","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","38174.18","28630.63","MEDICARE [2001]","HB NWH MEDICARE","21773.10","","Case rate ($21,773.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,342.31, add-ons for qualifying new technology services are included. If operating cost exceeds $65,484.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,455.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,259.82. The transfer operating threshold is the transfer adjustment factor * $20,342.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,513.27. The transfer capital threshold is the transfer adjustment factor * $1,513.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22184.18","22184.18","22184.18","1 through 10","19406.23","22530.1087","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","38174.18","28630.63","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","19406.23","","Case rate ($19,802.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $20,342.31, add-ons for qualifying new technology services are included. If operating cost exceeds $65,484.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,455.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $18,289.00. The transfer operating threshold is the transfer adjustment factor * $20,342.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,513.27. The transfer capital threshold is the transfer adjustment factor * $1,513.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19787.20","19787.20","19787.20","1 through 10","19406.23","22530.1087","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour Without Cc/McC","084","MS-DRG","","","","","","","","inpatient","","","22264.25","16698.19","MEDICARE [2001]","HB NWH MEDICARE","8280.98","","Case rate ($8,280.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $8,506.81, add-ons for qualifying new technology services are included. If operating cost exceeds $53,649.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,574.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,648.16. The transfer operating threshold is the transfer adjustment factor * $8,506.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $632.82. The transfer capital threshold is the transfer adjustment factor * $632.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9141.59","9141.59","9141.59","1 through 10","8115.36","9454.8729","other","Inpatient Replacement Plans DRG"
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"TRAY 0.00MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10136027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1530.90","1160.93","1884.08","89","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","5253.92","5253.92","5253.92","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1566.00","58","","12181.47","12181.47","12181.47","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1687.50","62.5","","1350.68","1350.68","1350.68","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","1910.74","891.94","1910.74","1 through 10","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","1829.79","1561.50","2617.12","88","1200.15","2103.57","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1359.46","1201.30","1689.00","61","1350","2118.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1718.92","1718.92","1718.92","1 through 10","1350","2118.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1910.74","1019.06","2344.84","74","1350","2118.15","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1530.90","1160.93","1884.08","89","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","5253.92","5253.92","5253.92","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2175.00","58","","12181.47","12181.47","12181.47","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2343.75","62.5","","1350.68","1350.68","1350.68","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","1910.74","891.94","1910.74","1 through 10","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","1829.79","1561.50","2617.12","88","1666.88","2921.63","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1359.46","1201.30","1689.00","61","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1718.92","1718.92","1718.92","1 through 10","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1910.74","1019.06","2344.84","74","1875","2941.88","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","AETNA [1001]","HB CH AETNA HMO / PPO","1979.69","58.3","","1530.90","1160.93","1884.08","89","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1799.72","53","","5253.92","5253.92","5253.92","1 through 10","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1969.51","58","","12181.47","12181.47","12181.47","1 through 10","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2122.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1509.39","44.45","","1910.74","891.94","1910.74","1 through 10","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","WELLPOINT [1015]","HB CH WELLPOINT","2645.59","77.91","","1829.79","1561.50","2617.12","88","1509.39","2645.59","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2013.65","59.3","","1359.46","1201.30","1689.00","61","1697.85","2663.93","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2013.65","59.3","","1718.92","1718.92","1718.92","1 through 10","1697.85","2663.93","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2663.93","78.45","","1910.74","1019.06","2344.84","74","1697.85","2663.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","1530.90","1160.93","1884.08","89","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","5253.92","5253.92","5253.92","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1151.01","58","","12181.47","12181.47","12181.47","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1240.31","62.5","","1350.68","1350.68","1350.68","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","1910.74","891.94","1910.74","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","1829.79","1561.50","2617.12","88","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1359.46","1201.30","1689.00","61","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1718.92","1718.92","1718.92","1 through 10","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","1910.74","1019.06","2344.84","74","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","1530.90","1160.93","1884.08","89","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","5253.92","5253.92","5253.92","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1151.01","58","","12181.47","12181.47","12181.47","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1240.31","62.5","","1350.68","1350.68","1350.68","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","1910.74","891.94","1910.74","1 through 10","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","1829.79","1561.50","2617.12","88","882.11","1546.12","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1359.46","1201.30","1689.00","61","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1718.92","1718.92","1718.92","1 through 10","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","1910.74","1019.06","2344.84","74","992.25","1556.84","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","AETNA [1001]","HB CH AETNA HMO / PPO","1787.48","58.3","","1530.90","1160.93","1884.08","89","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1624.98","53","","5253.92","5253.92","5253.92","1 through 10","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1778.28","58","","12181.47","12181.47","12181.47","1 through 10","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1916.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1362.84","44.45","","1910.74","891.94","1910.74","1 through 10","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","WELLPOINT [1015]","HB CH WELLPOINT","2388.72","77.91","","1829.79","1561.50","2617.12","88","1362.84","2388.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1818.14","59.3","","1359.46","1201.30","1689.00","61","1533","2405.28","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1818.14","59.3","","1718.92","1718.92","1718.92","1 through 10","1533","2405.28","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2405.28","78.45","","1910.74","1019.06","2344.84","74","1533","2405.28","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1530.90","1160.93","1884.08","89","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","5253.92","5253.92","5253.92","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2338.85","58","","12181.47","12181.47","12181.47","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2520.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1792.45","44.45","","1910.74","891.94","1910.74","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","1829.79","1561.50","2617.12","88","1792.45","3141.72","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1359.46","1201.30","1689.00","61","2016.25","3163.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1718.92","1718.92","1718.92","1 through 10","2016.25","3163.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","1910.74","1019.06","2344.84","74","2016.25","3163.5","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1530.90","1160.93","1884.08","89","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","5253.92","5253.92","5253.92","1 through 10","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2031.62","58","","12181.47","12181.47","12181.47","1 through 10","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2189.25","62.5","","1350.68","1350.68","1350.68","1 through 10","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.99","44.45","","1910.74","891.94","1910.74","1 through 10","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","1829.79","1561.50","2617.12","88","1556.99","2729.03","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1359.46","1201.30","1689.00","61","1751.4","2747.95","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1718.92","1718.92","1718.92","1 through 10","1751.4","2747.95","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","1910.74","1019.06","2344.84","74","1751.4","2747.95","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","AETNA [1001]","HB CH AETNA HMO / PPO","4764.28","58.3","","1530.90","1160.93","1884.08","89","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4331.16","53","","5253.92","5253.92","5253.92","1 through 10","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4739.76","58","","12181.47","12181.47","12181.47","1 through 10","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5107.50","62.5","","1350.68","1350.68","1350.68","1 through 10","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3632.45","44.45","","1910.74","891.94","1910.74","1 through 10","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","WELLPOINT [1015]","HB CH WELLPOINT","6366.81","77.91","","1829.79","1561.50","2617.12","88","3632.45","6366.81","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4846.00","59.3","","1359.46","1201.30","1689.00","61","4086","6410.93","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4846.00","59.3","","1718.92","1718.92","1718.92","1 through 10","4086","6410.93","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6410.93","78.45","","1910.74","1019.06","2344.84","74","4086","6410.93","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1530.90","1160.93","1884.08","89","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","5253.92","5253.92","5253.92","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2338.85","58","","12181.47","12181.47","12181.47","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2520.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1792.45","44.45","","1910.74","891.94","1910.74","1 through 10","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","1829.79","1561.50","2617.12","88","1792.45","3141.72","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1359.46","1201.30","1689.00","61","2016.25","3163.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1718.92","1718.92","1718.92","1 through 10","2016.25","3163.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 3 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131996","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","1910.74","1019.06","2344.84","74","2016.25","3163.5","percent of total billed charges",""
"Treatment Room Procedure","PX-76001357","CDM","57295","CPT","0761","RC","","","","both","","","8940.00","6705.00","AETNA [1001]","HB CH AETNA HMO / PPO","5212.02","58.3","","10149.87","10149.87","10149.87","1 through 10","3835.26","6965.15","percent of total billed charges",""
"Treatment Room Procedure","PX-76001357","CDM","57295","CPT","0761","RC","","","","outpatient","","","8940.00","6705.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4386.86","49.07","","3899.16","3899.16","3899.16","1 through 10","3576","7013.43","percent of total billed charges",""
"Treatment Room Procedure","PX-76001357","CDM","57295","CPT","0761","RC","","","","outpatient","","","8940.00","6705.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4478.94","50.1","","3823.55","3823.55","3823.55","1 through 10","3576","7013.43","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0300","RC","","","","inpatient","","","154.00","115.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.24","56","","87.90","87.90","87.90","1 through 10","86.24","108.72","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0300","RC","","","","inpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.72","70.6","","68.34","68.34","68.34","1 through 10","86.24","108.72","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","AETNA [1001]","HB CH AETNA HMO / PPO","89.78","58.3","","85.05","85.05","85.05","486","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","112.42","73","","109.50","109.50","109.50","1 through 10","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","112.42","73","","85.05","24.17","85.05","1 through 10","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","TRICARE [160005]","HB NWH TRICARE","146.30","95","","15.95","15.15","31.90","15","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.45","44.45","","115.32","68.34","115.32","11","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.45","44.45","","115.32","68.34","115.32","1 through 10","12.98","146.3","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","154.00","115.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.32","59.3","","87.90","87.90","87.90","393","13.65","120.81","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.81","78.45","","115.32","68.34","115.32","369","13.65","120.81","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","AETNA [1001]","HB CH AETNA HMO / PPO","1931.19","58.3","","1530.90","1160.93","1884.08","89","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1755.63","53","","5253.92","5253.92","5253.92","1 through 10","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1921.25","58","","12181.47","12181.47","12181.47","1 through 10","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2070.31","62.5","","1350.68","1350.68","1350.68","1 through 10","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1472.41","44.45","","1910.74","891.94","1910.74","1 through 10","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","WELLPOINT [1015]","HB CH WELLPOINT","2580.77","77.91","","1829.79","1561.50","2617.12","88","1472.41","2580.77","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1964.31","59.3","","1359.46","1201.30","1689.00","61","1656.25","2598.66","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1964.31","59.3","","1718.92","1718.92","1718.92","1 through 10","1656.25","2598.66","percent of total billed charges",""
"TRIAL KNEE 11MM SM COMPONENT TIBIAL DURATION ALL POLY KRH","SUP-ITM-10035453","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2598.66","78.45","","1910.74","1019.06","2344.84","74","1656.25","2598.66","percent of total billed charges",""
"Triamcinolone Ace Inj","PX-63600364","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.57","6.43","AETNA [1001]","HB CH AETNA HMO / PPO","5.00","58.3","","5.31","5.31","5.31","25","2.84","6.26","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.87","6.65","AETNA [1001]","HB CH AETNA HMO / PPO","5.17","58.3","","5.31","5.31","5.31","25","2.84","6.48","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.87","6.65","AETNA [1001]","HB CH AETNA HMO / PPO","5.17","58.3","","5.31","5.31","5.31","25","2.84","6.48","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB CH AETNA HMO / PPO","130.01","58.3","","123.04","123.04","123.04","99","34.39","211.85","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","TRICARE [160005]","HB NWH TRICARE","211.85","95","","42.28","42.28","42.28","1 through 10","34.39","211.85","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","211.85","95","","35.09","35.09","35.09","1 through 10","34.39","211.85","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.12","44.45","","166.83","98.87","166.83","1 through 10","34.39","211.85","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","WELLPOINT [1015]","HB CH WELLPOINT","173.74","77.91","","170.91","170.91","170.91","35","34.39","211.85","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","127.16","97","26.86","174.94","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","127.16","1 through 10","26.86","174.94","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.94","78.45","","166.83","98.87","166.83","83","26.86","174.94","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","49.00","36.75","AETNA [1001]","HB CH AETNA HMO / PPO","28.57","58.3","","27.22","27.22","27.22","79","5.63","46.55","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","49.00","36.75","TRICARE [160005]","HB NWH TRICARE","46.55","95","","6.92","5.19","6.92","1 through 10","5.63","46.55","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.78","44.45","","36.90","36.90","36.90","1 through 10","5.63","46.55","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","49.00","36.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","29.06","59.3","","28.13","28.13","28.13","92","5.92","38.44","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","38.44","78.45","","36.90","21.87","36.90","87","5.92","38.44","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","142.00","106.50","AETNA [1001]","HB CH AETNA HMO / PPO","82.79","58.3","","78.25","78.25","156.50","33","16.6","134.9","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","142.00","106.50","TRICARE [160005]","HB NWH TRICARE","134.90","95","","19.39","19.39","19.39","1 through 10","16.6","134.9","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.12","44.45","","106.09","61.96","106.09","1 through 10","16.6","134.9","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","142.00","106.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.21","59.3","","80.87","80.87","80.87","25","17.47","111.4","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","111.40","78.45","","106.09","62.87","106.09","16","17.47","111.4","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.79","44.45","","130.70","130.70","130.70","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.78","59.3","","99.62","99.62","99.62","1 through 10","15.7","137.29","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","130.70","130.70","130.70","1 through 10","15.7","137.29","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","82","13.9","112.1","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","118.00","88.50","TRICARE [160005]","HB NWH TRICARE","112.10","95","","16.24","16.24","17.09","1 through 10","13.9","112.1","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.45","44.45","","52.39","52.39","88.41","1 through 10","13.9","112.1","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","118.00","88.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.45","44.45","","52.39","52.39","52.39","1 through 10","13.9","112.1","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","67.39","80","14.61","92.57","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","88.41","90","14.61","92.57","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","AETNA [1001]","HB CH AETNA HMO / PPO","4429.63","58.3","","677.00","677.00","677.00","1 through 10","2766.13","5919.6","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3990.49","3582.14","3990.49","1 through 10","2766.13","5919.6","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","MEDICARE [2001]","HB NWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","4347.62","4347.62","1 through 10","2766.13","5919.6","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","2766.13","5919.6","per diem",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4472.81","4472.81","4472.81","1 through 10","2766.13","7939.38","other","ASC "
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4574.03","2239.57","4574.03","1 through 10","2766.13","7939.38","other","ASC "
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4505.61","59.3","","19387.23","19387.23","19387.23","1 through 10","2766.13","7939.38","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4051.40","4051.40","4051.40","1 through 10","2766.13","7939.38","other","Multiple Surgery"
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","AETNA [1001]","HB CH AETNA HMO / PPO","728.75","58.3","","677.00","677.00","677.00","1 through 10","536.25","973.88","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","469.25","469.25","469.25","1 through 10","536.25","973.88","per diem",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4610.00","3457.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2128.87","2128.87","2128.87","1 through 10","721.77","3591.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2504.65","2504.65","2504.65","1 through 10","1548.96","7178","other","ASC "
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2561.33","1254.10","2561.33","1 through 10","1548.96","7178","other","ASC "
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","4971.00","3728.25","MEDICARE [2001]","HB NWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1548.96","3872.91","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","4971.00","3728.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3908.86","3908.86","3908.86","1 through 10","1548.96","3872.91","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","outpatient","","","4971.00","3728.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3500.65","3500.65","3500.65","1 through 10","1548.96","7178","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","AETNA [1001]","HB CH AETNA HMO / PPO","2687.63","58.3","","1692.50","1128.33","1692.50","1 through 10","1548.96","3591.65","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1446.70","1446.70","1446.70","1 through 10","1548.96","3591.65","per diem",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1404.20","1404.20","1404.20","1 through 10","1548.96","3591.65","per diem",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,877). Procedure 2, Per diem ($938.50). Procedures 3 - 9999, Per diem ($469.25).","1877.00","1877.00","1877.00","1 through 10","1548.96","3591.65","per diem",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2504.65","1252.33","2557.79","1 through 10","1548.96","4472.66","other","ASC "
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2508.19","1280.67","2561.33","13","1548.96","4472.66","other","ASC "
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2733.73","59.3","","2422.52","2422.52","2422.52","1 through 10","1548.96","4472.66","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3640.06","3640.06","3640.06","1 through 10","1548.96","4472.66","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","11477.79","3825.93","11477.79","1 through 10","1548.96","4472.66","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3616.55","78.45","","1147.43","1147.43","1883.45","1 through 10","1548.96","4472.66","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1278.90","1278.90","1278.90","1 through 10","1548.96","7178","other","ASC "
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2561.33","2561.33","2561.33","1 through 10","1548.96","7178","other","ASC "
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,702). Procedure 2, Per diem ($851). Procedures 3 - 9999, Per diem ($425.50).","1702.00","1702.00","1702.00","1 through 10","1548.96","3591.65","per diem",""
"TROCAR BALLOON 10MM STRUCTURAL SPACEMAKER LF STERILE DISP BX/5EA","SUP-ITM-10002678","CDM","C1726","HCPCS","0272","RC","","","","both","","","445.94","334.45","WELLPOINT [1015]","HB CH WELLPOINT","347.43","77.91","","582.67","582.67","582.67","1 through 10","198.22","347.43","percent of total billed charges",""
"TROCAR BALLOON 10MM STRUCTURAL SPACEMAKER LF STERILE DISP BX/5EA","SUP-ITM-10002678","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","445.94","334.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","349.84","78.45","","394.74","331.66","1115.07","1 through 10","222.97","349.84","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","AETNA [1001]","HB CH AETNA HMO / PPO","240.66","58.3","","1530.90","1160.93","1884.08","89","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","218.78","53","","5253.92","5253.92","5253.92","1 through 10","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","239.42","58","","12181.47","12181.47","12181.47","1 through 10","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","258.00","62.5","","1350.68","1350.68","1350.68","1 through 10","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.49","44.45","","1910.74","891.94","1910.74","1 through 10","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","both","","","412.80","309.60","WELLPOINT [1015]","HB CH WELLPOINT","321.61","77.91","","1829.79","1561.50","2617.12","88","183.49","321.61","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","412.80","309.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","244.79","59.3","","1359.46","1201.30","1689.00","61","206.4","323.84","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","412.80","309.60","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","244.79","59.3","","1718.92","1718.92","1718.92","1 through 10","206.4","323.84","percent of total billed charges",""
"TROCAR GUIDE 7.3MM WIRE PROCEDURE CANNULATED SCREW","SUP-ITM-10038952","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","412.80","309.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","323.84","78.45","","1910.74","1019.06","2344.84","74","206.4","323.84","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","AETNA [1001]","HB CH AETNA HMO / PPO","1894.80","58.3","","464.71","67.87","1012.10","221","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1894.80","58.3","","293.04","293.04","293.04","11","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1722.54","53","","983.89","983.89","983.89","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1885.05","58","","677.18","677.18","677.18","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2031.30","62.5","","46.58","46.58","46.58","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2372.56","73","","747.15","747.15","747.15","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1444.66","44.45","","1141.67","481.21","1141.67","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1444.66","44.45","","76.54","76.54","76.54","1 through 10","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","WELLPOINT [1015]","HB CH WELLPOINT","2532.14","77.91","","273.64","94.28","1367.51","138","1444.66","2532.14","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1927.30","59.3","","720.78","230.14","2010.94","427","1625.04","2549.69","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1927.30","59.3","","344.45","344.45","344.45","1 through 10","1625.04","2549.69","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2549.69","78.45","","1120.13","1120.13","1120.13","1 through 10","1625.04","2549.69","percent of total billed charges",""
"TROCHANTER NAIL 11MM 170 125DEG FIXATION TFN ADVANCED TI CANNULATED","SUP-ITM-10164099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2549.69","78.45","","456.17","105.33","1284.66","242","1625.04","2549.69","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1530.90","1160.93","1884.08","89","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","5253.92","5253.92","5253.92","1 through 10","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4539.08","58","","12181.47","12181.47","12181.47","1 through 10","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","4891.25","62.5","","1350.68","1350.68","1350.68","1 through 10","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3478.66","44.45","","1910.74","891.94","1910.74","1 through 10","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","1829.79","1561.50","2617.12","88","3478.66","6097.24","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1359.46","1201.30","1689.00","61","3913","6139.5","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1718.92","1718.92","1718.92","1 through 10","3913","6139.5","percent of total billed charges",""
"TROCHANTER POST 15DEG FEMORAL HIP COMPONENT PROXIMALIMAL ANTEVERTED LEFT","SUP-ITM-10035509","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","1910.74","1019.06","2344.84","74","3913","6139.5","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0300","RC","","","","inpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.66","70.6","","164.52","48.75","164.52","1 through 10","61.6","77.66","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","110.00","82.50","AETNA [1001]","HB CH AETNA HMO / PPO","64.13","58.3","","60.67","1.45","60.67","69","12.22","104.5","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","110.00","82.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.23","59.3","","62.70","55.66","229.49","100","10.14","86.3","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","82.26","48.75","321.00","48","10.14","86.3","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","AETNA [1001]","HB CH AETNA HMO / PPO","290.33","58.3","","464.71","67.87","1012.10","221","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","290.33","58.3","","293.04","293.04","293.04","11","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","263.94","53","","983.89","983.89","983.89","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","288.84","58","","677.18","677.18","677.18","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","311.25","62.5","","46.58","46.58","46.58","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","363.54","73","","747.15","747.15","747.15","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.36","44.45","","1141.67","481.21","1141.67","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.36","44.45","","76.54","76.54","76.54","1 through 10","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.00","373.50","WELLPOINT [1015]","HB CH WELLPOINT","387.99","77.91","","273.64","94.28","1367.51","138","221.36","387.99","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.00","373.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","295.31","59.3","","720.78","230.14","2010.94","427","249","390.68","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.00","373.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","295.31","59.3","","344.45","344.45","344.45","1 through 10","249","390.68","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.00","373.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","390.68","78.45","","1120.13","1120.13","1120.13","1 through 10","249","390.68","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","390.68","78.45","","456.17","105.33","1284.66","242","249","390.68","percent of total billed charges",""
"Tx Fx (M-P)/(I-P) Joint Open","PX-76000510","CDM","26746","CPT","0761","RC","","","","both","","","7571.00","5678.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3775.72","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3784.01","3784.01","3784.01","1 through 10","2361.01","5898.57","other","OPPS APC"
"Tx Fx Phalanx Prox W/Man Open","PX-76000507","CDM","26735","CPT","0761","RC","","","","both","","","6765.00","5073.75","AETNA [1001]","HB CH AETNA HMO / PPO","3944.00","58.3","","2492.72","2492.72","2492.72","1 through 10","2361.01","5270.61","percent of total billed charges",""
"Tx Fx Radial Dist Intra-Artic Opn","PX-76000462","CDM","25608","CPT","0761","RC","","","","both","","","3883.00","2912.25","AETNA [1001]","HB CH AETNA HMO / PPO","2263.79","58.3","","7293.89","7293.89","7293.89","1 through 10","1665.81","9357.58","percent of total billed charges",""
"Tx Fx Radial Dist Intra-Artic Opn","PX-76000462","CDM","25608","CPT","0761","RC","","","","both","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7658.95","7658.95","7658.95","1 through 10","1665.81","9357.58","other","OPPS APC"
"Tx Fx Radial Dist Intra-Artic Opn|BILATERAL PROCEDURE","PX-76000462","CDM","25608","CPT","0761","RC","","","50","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($4,827). Procedure 2, Per diem ($2,413.50). Procedures 3 - 9999, Per diem ($1,206.75).","4827.00","4827.00","4827.00","1 through 10","19928.61","29931.39","per diem",""
"Tx Fx Radial Distal 3+ Frag Open","PX-76000463","CDM","25609","CPT","0761","RC","","","","both","","","4936.00","3702.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","5129.63","","Case rate ($5,129.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","4470.49","4470.49","4470.49","1 through 10","2117.54","9357.58","other","Multiple Surgery"
"Tx Fx Radial Distal 3+ Frag Open","PX-76000463","CDM","25609","CPT","0761","RC","","","","both","","","4936.00","3702.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,606.75). Procedures 3 - 9999, Per diem ($804.50).","3218.00","3218.00","3218.00","1 through 10","2117.54","9357.58","per diem",""
"Tx Fx Radial Distal 3+ Frag Open","PX-76000463","CDM","25609","CPT","0761","RC","","","","both","","","4936.00","3702.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8313.94","7659.85","8321.44","1 through 10","2117.54","9357.58","other","OPPS APC"
"Tx Fx Radial Distal 3+ Frag Open","PX-76000463","CDM","25609","CPT","0761","RC","","","","outpatient","","","4936.00","3702.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","5129.63","","Case rate ($5,129.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5786.42","5786.42","5786.42","1 through 10","2468","12722.53","other","Multiple Surgery"
"Tx Fx Radial Distal 3+ Frag Open|BILATERAL PROCEDURE","PX-76000463","CDM","25609","CPT","0761","RC","","","50","both","","","4936.00","3702.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","16363.36","","APC Price ($16,363.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15035.64","15035.64","15035.64","1 through 10","14516.11","29931.39","other","OPPS APC"
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","AETNA [1001]","HB CH AETNA HMO / PPO","1113.71","58.3","","464.71","67.87","1012.10","221","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1113.71","58.3","","293.04","293.04","293.04","11","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1012.46","53","","983.89","983.89","983.89","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1107.98","58","","677.18","677.18","677.18","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1193.94","62.5","","46.58","46.58","46.58","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1394.53","73","","747.15","747.15","747.15","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.13","44.45","","1141.67","481.21","1141.67","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.13","44.45","","76.54","76.54","76.54","1 through 10","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.31","1432.73","WELLPOINT [1015]","HB CH WELLPOINT","1488.32","77.91","","273.64","94.28","1367.51","138","849.13","1488.32","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.31","1432.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","1132.81","59.3","","720.78","230.14","2010.94","427","955.16","1498.64","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.31","1432.73","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1132.81","59.3","","344.45","344.45","344.45","1 through 10","955.16","1498.64","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.31","1432.73","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1498.64","78.45","","1120.13","1120.13","1120.13","1 through 10","955.16","1498.64","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.31","1432.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1498.64","78.45","","456.17","105.33","1284.66","242","955.16","1498.64","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","AETNA [1001]","HB CH AETNA HMO / PPO","1526.88","58.3","","464.71","67.87","1012.10","221","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1526.88","58.3","","293.04","293.04","293.04","11","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1388.07","53","","983.89","983.89","983.89","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1519.02","58","","677.18","677.18","677.18","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1636.88","62.5","","46.58","46.58","46.58","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1911.87","73","","747.15","747.15","747.15","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1164.15","44.45","","1141.67","481.21","1141.67","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1164.15","44.45","","76.54","76.54","76.54","1 through 10","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","WELLPOINT [1015]","HB CH WELLPOINT","2040.46","77.91","","273.64","94.28","1367.51","138","1164.15","2040.46","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1553.07","59.3","","720.78","230.14","2010.94","427","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1553.07","59.3","","344.45","344.45","344.45","1 through 10","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2054.61","78.45","","1120.13","1120.13","1120.13","1 through 10","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2054.61","78.45","","456.17","105.33","1284.66","242","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","AETNA [1001]","HB CH AETNA HMO / PPO","1687.79","58.3","","464.71","67.87","1012.10","221","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1687.79","58.3","","293.04","293.04","293.04","11","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1534.35","53","","983.89","983.89","983.89","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1679.10","58","","677.18","677.18","677.18","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1809.38","62.5","","46.58","46.58","46.58","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2113.35","73","","747.15","747.15","747.15","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.83","44.45","","1141.67","481.21","1141.67","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.83","44.45","","76.54","76.54","76.54","1 through 10","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","WELLPOINT [1015]","HB CH WELLPOINT","2255.49","77.91","","273.64","94.28","1367.51","138","1286.83","2255.49","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1716.74","59.3","","720.78","230.14","2010.94","427","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1716.74","59.3","","344.45","344.45","344.45","1 through 10","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2271.13","78.45","","1120.13","1120.13","1120.13","1 through 10","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2271.13","78.45","","456.17","105.33","1284.66","242","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","AETNA [1001]","HB CH AETNA HMO / PPO","1897.67","58.3","","464.71","67.87","1012.10","221","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1897.67","58.3","","293.04","293.04","293.04","11","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.15","53","","983.89","983.89","983.89","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1887.90","58","","677.18","677.18","677.18","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2034.38","62.5","","46.58","46.58","46.58","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2376.15","73","","747.15","747.15","747.15","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.85","44.45","","1141.67","481.21","1141.67","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.85","44.45","","76.54","76.54","76.54","1 through 10","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB CH WELLPOINT","2535.97","77.91","","273.64","94.28","1367.51","138","1446.85","2535.97","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.22","59.3","","720.78","230.14","2010.94","427","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1930.22","59.3","","344.45","344.45","344.45","1 through 10","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2553.55","78.45","","1120.13","1120.13","1120.13","1 through 10","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2553.55","78.45","","456.17","105.33","1284.66","242","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","AETNA [1001]","HB CH AETNA HMO / PPO","2174.01","58.3","","464.71","67.87","1012.10","221","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2174.01","58.3","","293.04","293.04","293.04","11","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1976.37","53","","983.89","983.89","983.89","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2162.82","58","","677.18","677.18","677.18","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2330.63","62.5","","46.58","46.58","46.58","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2722.17","73","","747.15","747.15","747.15","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1657.54","44.45","","1141.67","481.21","1141.67","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1657.54","44.45","","76.54","76.54","76.54","1 through 10","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","both","","","3729.00","2796.75","WELLPOINT [1015]","HB CH WELLPOINT","2905.26","77.91","","273.64","94.28","1367.51","138","1657.54","2905.26","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3729.00","2796.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2211.30","59.3","","720.78","230.14","2010.94","427","1864.5","2925.4","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3729.00","2796.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2211.30","59.3","","344.45","344.45","344.45","1 through 10","1864.5","2925.4","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3729.00","2796.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2925.40","78.45","","1120.13","1120.13","1120.13","1 through 10","1864.5","2925.4","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 3 HOLE RIGHT","SUP-ITM-10198218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3729.00","2796.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2925.40","78.45","","456.17","105.33","1284.66","242","1864.5","2925.4","percent of total billed charges",""
"Uncomplicated Peptic Ulcer With McC","383","MS-DRG","","","","","","","","inpatient","","","28630.44","21472.83","MEDICARE [2001]","HB NWH MEDICARE","13152.83","","Case rate ($13,152.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $12,288.52, add-ons for qualifying new technology services are included. If operating cost exceeds $57,430.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,856.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,238.68. The transfer operating threshold is the transfer adjustment factor * $12,288.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $914.15. The transfer capital threshold is the transfer adjustment factor * $914.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12065.75","12065.75","12065.75","1 through 10","11723.03","13152.83","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","37468.07","28101.05","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7628.11","","Case rate ($7,405.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $52,750.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,507.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,839.97. The transfer operating threshold is the transfer adjustment factor * $7,607.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $565.95. The transfer capital threshold is the transfer adjustment factor * $565.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7832.78","7832.78","7832.78","1 through 10","7257.81","8599.4744","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","37468.07","28101.05","MEDICARE [2001]","HB NWH MEDICARE","7405.93","","Case rate ($7,405.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $52,750.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,507.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,839.97. The transfer operating threshold is the transfer adjustment factor * $7,607.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $565.95. The transfer capital threshold is the transfer adjustment factor * $565.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8299.61","8299.61","8299.61","1 through 10","7257.81","8599.4744","other","Inpatient Replacement Plans DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","37468.07","28101.05","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","7257.81","","Case rate ($7,405.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $52,750.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,507.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,839.97. The transfer operating threshold is the transfer adjustment factor * $7,607.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $565.95. The transfer capital threshold is the transfer adjustment factor * $565.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8768.31","8768.31","8768.31","1 through 10","7257.81","8599.4744","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","37468.07","28101.05","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7257.81","","Case rate ($7,405.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,607.89, add-ons for qualifying new technology services are included. If operating cost exceeds $52,750.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,507.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,839.97. The transfer operating threshold is the transfer adjustment factor * $7,607.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $565.95. The transfer capital threshold is the transfer adjustment factor * $565.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7446.26","7446.26","7446.26","1 through 10","7257.81","8599.4744","other","Inpatient DRG"
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","37","3.87","31.35","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","33.00","24.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","24.09","73","","18.14","18.14","18.14","1 through 10","3.87","31.35","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.75","18.75","31","4.07","25.89","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","24.60","24.60","32","4.07","25.89","percent of total billed charges",""
"Urethral And Transurethral Procedures,MAJOR","446","DRG","","","","","","","","inpatient","","","29832.65","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13118.5446","","Fee schedule rate ($30,497.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13118.5446","30497.24","30497.24","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MINOR","446","DRG","","","","","","","","inpatient","","","24641.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21291.04","","Standard inlier is a Case rate ($21,291.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $31,981, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,022.17) for the length of stay and the standard reimbursement.","21291.03","21291.03","21291.03","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MINOR","446","DRG","","","","","","","","inpatient","","","24641.28","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","9678.49","","Fee schedule rate ($9,678.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9678.49","9678.49","9678.49","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MINOR","446","DRG","","","","","","","","inpatient","","","24641.28","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6055.68","","Case rate ($6,524.04). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $48,954.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6540.82","6540.82","6540.82","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MODERATE","446","DRG","","","","","","","","inpatient","","","32603.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24135.02","","Standard inlier is a Case rate ($24,135.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $36,408, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,426.06) for the length of stay and the standard reimbursement.","24135.01","24135.01","24135.01","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MODERATE","446","DRG","","","","","","","","inpatient","","","32603.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13118.5446","","Fee schedule rate ($30,497.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13118.5446","15782.12","15782.12","1 through 10","6055.68","127476.65","case rate",""
"Urethral And Transurethral Procedures,MODERATE","446","DRG","","","","","","","","inpatient","","","32603.14","","MASSHEALTH [3001]","HB NWH MEDICAID","7718.97","","Case rate ($8,315.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $50,745.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5895.49","5895.49","5895.49","1 through 10","6055.68","127476.65","case rate",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0300","RC","","","","inpatient","","","56.00","42.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.36","56","","31.64","31.64","31.64","1 through 10","31.36","39.54","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","AETNA [1001]","HB CH AETNA HMO / PPO","32.65","58.3","","30.62","30.62","30.62","215","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","CHAMPVA [160001]","HB NWH TRICARE","53.20","95","","5.45","5.45","5.45","1 through 10","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","40.88","73","","30.62","3.49","30.62","1 through 10","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","TRICARE [160005]","HB NWH TRICARE","53.20","95","","5.45","5.45","5.45","1 through 10","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.89","44.45","","41.52","41.52","41.52","1 through 10","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.89","44.45","","24.60","24.60","24.60","1 through 10","4.43","53.2","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","56.00","42.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","33.21","59.3","","31.64","31.64","31.64","193","4.65","43.93","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","41.52","24.60","41.52","151","4.65","43.93","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","1 through 10","4.89","34.52","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0300","RC","","","","inpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.12","70.6","","16.40","16.40","507.00","1 through 10","20.72","26.12","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","AETNA [1001]","HB CH AETNA HMO / PPO","21.57","58.3","","20.41","20.41","20.41","553","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","27.01","73","","26.28","26.28","26.28","1 through 10","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","27.01","73","","20.41","20.41","20.41","1 through 10","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","TRICARE [160005]","HB NWH TRICARE","35.15","95","","3.63","3.63","3.82","1 through 10","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.45","44.45","","27.68","16.40","27.68","24","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.45","44.45","","16.40","16.40","16.40","1 through 10","3.11","35.15","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.94","59.3","","21.10","21.10","27.19","532","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","21.94","59.3","","21.10","21.10","21.10","1 through 10","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","36.00","26.54","36.00","1 through 10","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","16.40","27.68","459","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","AETNA [1001]","HB CH AETNA HMO / PPO","18.07","58.3","","17.01","17.01","17.01","223","2.21","29.45","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","22.63","73","","21.90","21.90","21.90","1 through 10","2.21","29.45","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","22.63","73","","17.01","2.03","17.01","1 through 10","2.21","29.45","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.78","44.45","","13.67","13.47","23.06","1 through 10","2.21","29.45","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.78","44.45","","13.67","13.67","13.67","1 through 10","2.21","29.45","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","31.00","23.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","18.38","59.3","","17.58","17.58","17.58","214","2.31","24.32","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.32","78.45","","23.06","13.67","23.06","188","2.31","24.32","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","both","","","35.00","26.25","AETNA [1001]","HB CH AETNA HMO / PPO","20.41","58.3","","19.28","19.28","19.28","1 through 10","2.99","33.25","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","outpatient","","","35.00","26.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.76","59.3","","19.92","19.92","19.92","1 through 10","3.14","27.46","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.46","78.45","","26.14","12.00","26.14","1 through 10","3.14","27.46","percent of total billed charges",""
"Urinalysis Nonauto W/O Micro","PX-30001375","CDM","81002","CPT","0307","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.75","18.75","1 through 10","2.64","25.89","percent of total billed charges",""
"Urinalysis Nonauto W/O Micro","PX-30001375","CDM","81002","CPT","0307","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","24.60","24.60","1 through 10","2.64","25.89","percent of total billed charges",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","26980.81","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8432.373","","Fee schedule rate ($17,396.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8432.373","30972.12","30972.12","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","26980.81","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","10361.18","","Fee schedule rate ($10,361.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8550.25","8550.25","8550.25","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","26980.81","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","10878.78","","Fee schedule rate ($10,878.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10361.18","10361.18","10361.18","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","17731.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14557.01","","Standard inlier is a Case rate ($14,557.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,581, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,066.42) for the length of stay and the standard reimbursement.","13896.60","13896.60","14557.00","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","17731.79","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15637.13","","Standard inlier is a Case rate ($15,637.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $26,581, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,219.62) for the length of stay and the standard reimbursement.","14926.35","14926.35","15637.12","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","17731.79","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8432.373","","Fee schedule rate ($10,173.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8432.373","10173.56","10173.56","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","17731.79","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11190.82","","Fee schedule rate ($11,190.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10921.99","10921.99","10921.99","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","17731.79","","MASSHEALTH [3001]","HB NWH MEDICAID","4561.47","","Case rate ($4,914.26). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $47,344.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4926.90","4926.90","4926.90","1 through 10","4561.47","28703.61","case rate",""
"Urinary Stones With McC","693","MS-DRG","","","","","","","","inpatient","","","31132.64","23349.48","MEDICARE [2001]","HB NWH MEDICARE","12807.96","","Case rate ($12,807.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,966.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,108.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,832.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,917.80. The transfer operating threshold is the transfer adjustment factor * $11,966.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $890.18. The transfer capital threshold is the transfer adjustment factor * $890.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14058.97","14058.97","14058.97","1 through 10","11415.66","13801.29","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","16008.50","12006.37","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","6772.59","","Case rate ($6,772.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,957.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,099.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,459.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,255.04. The transfer operating threshold is the transfer adjustment factor * $6,957.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $517.55. The transfer capital threshold is the transfer adjustment factor * $517.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6738.37","6738.37","6738.37","1 through 10","6637.14","8024.15","other","Inpatient Replacement Plans DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","16008.50","12006.37","MEDICARE [2001]","HB NWH MEDICARE","6772.59","","Case rate ($6,772.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,957.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,099.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,459.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,255.04. The transfer operating threshold is the transfer adjustment factor * $6,957.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $517.55. The transfer capital threshold is the transfer adjustment factor * $517.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7471.21","7457.81","7471.21","1 through 10","6637.14","8024.15","other","Inpatient Replacement Plans DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","16008.50","12006.37","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","6637.14","","Case rate ($6,772.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,957.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,099.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,459.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,255.04. The transfer operating threshold is the transfer adjustment factor * $6,957.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $517.55. The transfer capital threshold is the transfer adjustment factor * $517.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6677.09","6668.58","7451.95","1 through 10","6637.14","8024.15","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","16008.50","12006.37","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","6637.14","","Case rate ($6,772.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,957.29, add-ons for qualifying new technology services are included. If operating cost exceeds $52,099.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,459.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,255.04. The transfer operating threshold is the transfer adjustment factor * $6,957.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $517.55. The transfer capital threshold is the transfer adjustment factor * $517.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6698.00","6698.00","6698.00","1 through 10","6637.14","8024.15","other","Inpatient DRG"
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0300","RC","","","","inpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.54","70.6","","32.35","32.35","32.35","1 through 10","40.88","51.54","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","AETNA [1001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","40.26","40.26","22","8.44","69.35","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","73.00","54.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.29","59.3","","71.85","41.61","222.05","39","6.52","57.27","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.27","78.45","","32.35","31.78","54.58","22","6.52","57.27","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","both","","","35.00","26.25","AETNA [1001]","HB CH AETNA HMO / PPO","20.41","58.3","","19.28","5.10","19.28","1 through 10","3.57","33.25","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","both","","","35.00","26.25","TRICARE [160005]","HB NWH TRICARE","33.25","95","","4.39","4.39","4.39","1 through 10","3.57","33.25","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","both","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.56","44.45","","26.14","26.13","26.14","1 through 10","3.57","33.25","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","35.00","26.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.76","59.3","","19.92","19.92","19.93","20","3.09","27.46","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.46","78.45","","26.14","15.49","26.14","22","3.09","27.46","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","30","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","FALLON HEALTH [1008]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","602.98","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","21","112.51","602.98","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.69","117.69","117.69","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","238","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","377.28","25","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","25","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.16","44.45","","365.85","365.85","365.85","1 through 10","112.51","602.98","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","455.30","455.30","455.30","1 through 10","112.51","648","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","476.26","103","112.51","648","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","272","112.51","648","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.82","59.3","","470.56","470.56","1411.68","49","112.51","648","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","98","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","320.65","52","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","648.00","78.45","","617.35","365.85","617.35","36","112.51","648","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0400","RC","","","","inpatient","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.90","70.6","","498.95","498.95","498.95","1 through 10","373.52","470.9","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","12","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","112.51","486.91","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","141.20","282.40","18","112.51","486.91","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","111","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","486.91","other","Tricare OPPS"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","13","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.24","126.29","350.24","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.48","44.45","","291.40","291.40","291.40","1 through 10","112.51","486.91","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","359.72","25","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.48","44.45","","295.68","295.68","295.68","1 through 10","112.51","486.91","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","367.98","367.98","638.20","1 through 10","112.51","523.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","384.92","72","112.51","523.26","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","523.26","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","168","112.51","523.26","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","395.53","59.3","","380.31","380.31","1623.74","35","112.51","523.26","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","769.58","89","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","806.70","44","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","523.26","78.45","","649.00","498.95","649.00","1 through 10","112.51","523.26","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","246.40","246.40","246.40","1 through 10","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.26","78.45","","498.95","295.68","498.95","28","112.51","523.26","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","377.65","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","377.65","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","377.65","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","67","112.51","377.65","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","371.28","13","112.51","377.65","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.60","123.77","1 through 10","112.51","377.65","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","WELLPOINT [1015]","HB CH WELLPOINT","298.40","77.91","","292.99","292.99","292.99","1 through 10","112.51","377.65","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","220.63","18","112.51","436.15","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","99.71","199.42","27","112.51","436.15","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","227.12","59.3","","217.99","217.99","217.99","1 through 10","112.51","436.15","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","12","112.51","436.15","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","134.45","134.45","268.90","1 through 10","112.51","436.15","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","300.46","78.45","","285.99","169.48","285.99","1 through 10","112.51","436.15","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","12","53.78","377.65","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","53.78","377.65","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","141.20","282.40","18","53.78","377.65","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","111","53.78","377.65","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","53.78","377.65","other","Tricare OPPS"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","13","53.78","377.65","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.24","126.29","350.24","1 through 10","53.78","377.65","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","291.40","291.40","291.40","1 through 10","53.78","377.65","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","359.72","25","53.78","377.65","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","295.68","295.68","295.68","1 through 10","53.78","377.65","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","inpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.43","70.6","","498.95","498.95","498.95","1 through 10","67.76","85.43","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","367.98","367.98","638.20","1 through 10","60.5","436.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","384.92","72","60.5","436.15","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","60.5","436.15","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","168","60.5","436.15","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","380.31","380.31","1623.74","35","60.5","436.15","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","769.58","89","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","806.70","44","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","649.00","498.95","649.00","1 through 10","60.5","436.15","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","246.40","246.40","246.40","1 through 10","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","498.95","295.68","498.95","28","60.5","436.15","percent of total billed charges",""
"US Breast Specimen","PX-40000150","CDM","76999","CPT","0402","RC","","","","both","","","1093.00","819.75","AETNA [1001]","HB CH AETNA HMO / PPO","637.22","58.3","","310.15","310.15","310.15","1 through 10","99.34","1039.44","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","AETNA [1001]","HB CH AETNA HMO / PPO","181.31","58.3","","171.23","171.23","342.47","19","62.3","231.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","355.12","177.56","355.12","1 through 10","62.3","231.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","156.37","156.37","312.74","70","62.3","231.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.24","44.45","","156.37","156.37","156.37","1 through 10","62.3","231.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","31","62.3","231.74","other","OPPS APC"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","184.42","59.3","","176.97","176.97","176.97","1 through 10","62.3","283.67","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","142.04","142.04","204.66","1 through 10","62.3","283.67","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","177.56","136.44","433.94","19","62.3","283.67","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","214.94","214.94","214.94","1 through 10","62.3","283.67","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","243.98","78.45","","464.36","163.63","464.36","38","62.3","283.67","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","311.00","233.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","1 through 10","90.15","94.75","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","311.00","233.25","FALLON HEALTH [1008]","HB NWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.47","1 through 10","90.15","94.75","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","311.00","233.25","MEDICARE [2001]","HB NWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","198.36","39","90.15","94.75","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","311.00","233.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.47","102.89","104.47","1 through 10","90.15","94.75","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.42","42.9","","275.18","275.18","604.00","1 through 10","133.42","425.5","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","377.65","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","1 through 10","112.51","377.65","other","Multiple Radiology"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","377.65","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","377.65","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","233.04","233.04","233.04","1 through 10","112.51","331.84","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","331.84","other","Multiple Imaging"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","18","112.51","331.84","other","Multiple Imaging"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","240.85","240.85","240.85","1 through 10","112.51","331.84","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","128.26","256.52","1 through 10","112.51","331.84","other","Multiple Radiology"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","331.84","other","Multiple Radiology"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.84","78.45","","315.98","315.98","315.98","1 through 10","112.51","331.84","percent of total billed charges",""
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","423.00","317.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.14","63.14","63.14","1 through 10","119.97","130.06","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","423.00","317.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.15","63.15","63.15","1 through 10","119.97","130.06","other","OPPS APC"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","249.48","498.96","1 through 10","112.51","376.91","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","452.00","339.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.33","160.33","160.33","1 through 10","112.51","376.91","other","Multiple Radiology"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","452.00","339.00","WELLPOINT [1015]","HB CH WELLPOINT","352.15","77.91","","346.54","346.54","346.54","1 through 10","112.51","376.91","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.59","78.45","","338.27","200.46","338.27","15","112.51","354.59","percent of total billed charges",""
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","both","","","633.00","474.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","462.09","other","Multiple Radiology"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","633.00","474.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","365.35","365.35","365.35","1 through 10","112.51","496.59","other","Multiple Imaging"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","633.00","474.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","496.59","other","Multiple Imaging"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","633.00","474.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","375.37","59.3","","360.98","360.98","360.98","1 through 10","112.51","496.59","percent of total billed charges",""
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","633.00","474.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","496.59","other","Multiple Radiology"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","633.00","474.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","496.59","78.45","","473.58","473.58","473.58","1 through 10","112.51","496.59","percent of total billed charges",""
"US Extremity Non Vascular Complete","PX-40000062","CDM","76881","CPT","0402","RC","","","","both","","","709.00","531.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","517.57","other","OPPS APC"
"US Extremity Non Vascular Complete","PX-40000062","CDM","76881","CPT","0402","RC","","","","both","","","709.00","531.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","517.57","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0400","RC","","","","inpatient","","","523.00","392.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","292.88","56","","298.27","298.27","298.27","1 through 10","292.88","369.24","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","AETNA [1001]","HB CH AETNA HMO / PPO","304.91","58.3","","288.60","288.60","577.21","29","119.97","423.04","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","CHAMPVA [160001]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.99","119.99","119.99","1 through 10","119.97","423.04","other","Tricare OPPS"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","381.79","73","","288.60","288.60","288.60","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","153.04","1 through 10","119.97","423.04","other","Tricare OPPS"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.47","44.45","","391.32","391.32","391.32","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","523.00","392.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","310.14","59.3","","298.27","298.27","298.27","149","199.42","436.15","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","523.00","392.25","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","436.15","","Case rate ($436.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","421.40","421.40","421.40","1 through 10","199.42","436.15","other","Multiple Imaging Pregnancy Ultrasound"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","410.29","78.45","","391.32","231.90","391.32","129","199.42","436.15","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0400","RC","","","","inpatient","","","533.00","399.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","298.48","56","","303.55","303.55","303.55","1 through 10","298.48","376.3","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","533.00","399.75","AETNA [1001]","HB CH AETNA HMO / PPO","310.74","58.3","","293.71","293.71","293.71","11","119.97","423.04","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","533.00","399.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","389.09","73","","80.14","80.14","80.14","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.92","44.45","","398.24","398.24","398.24","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","533.00","399.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.07","59.3","","303.55","303.55","303.55","40","199.42","418.14","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.14","78.45","","398.24","236.00","398.24","44","199.42","418.14","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","422.00","316.50","AETNA [1001]","HB CH AETNA HMO / PPO","246.03","58.3","","232.47","232.47","232.47","14","187.58","360.14","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.58","44.45","","186.80","186.80","186.80","1 through 10","187.58","360.14","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","422.00","316.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.25","59.3","","240.26","240.26","240.26","15","211","331.06","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.06","78.45","","315.21","91.80","315.21","1 through 10","211","331.06","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","outpatient","","","215.00","161.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","127.50","59.3","","122.47","122.47","122.47","1 through 10","95.57","168.67","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","outpatient","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","168.67","78.45","","160.68","160.68","160.68","1 through 10","95.57","168.67","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","outpatient","","","1219.00","914.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","722.87","59.3","","694.41","694.41","694.41","1 through 10","541.85","956.31","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","outpatient","","","1219.00","914.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","541.85","44.45","","539.89","539.89","539.89","1 through 10","541.85","956.31","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","726.00","544.50","AETNA [1001]","HB CH AETNA HMO / PPO","423.26","58.3","","400.30","400.30","400.30","1 through 10","261.88","529.98","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","726.00","544.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","529.98","73","","400.30","400.30","400.30","1 through 10","261.88","529.98","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.71","44.45","","321.65","321.65","321.65","1 through 10","261.88","529.98","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","726.00","544.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","430.52","59.3","","413.72","413.72","413.72","1 through 10","363","569.55","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","569.55","78.45","","542.77","321.65","542.77","12","363","569.55","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","AETNA [1001]","HB CH AETNA HMO / PPO","136.42","58.3","","129.28","129.28","129.28","1 through 10","104.01","182.31","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","146.25","62.5","","146.96","146.96","146.96","1 through 10","104.01","182.31","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","170.82","73","","124.64","124.64","124.64","1 through 10","104.01","182.31","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB CH WELLPOINT","182.31","77.91","","179.57","179.57","179.57","1 through 10","104.01","182.31","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","234.00","175.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","138.76","59.3","","133.61","133.61","133.61","1 through 10","117","183.57","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","183.57","78.45","","175.29","103.88","175.29","1 through 10","117","183.57","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","631.00","473.25","AETNA [1001]","HB CH AETNA HMO / PPO","367.87","58.3","","348.14","348.14","348.14","1 through 10","99.34","460.63","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","631.00","473.25","TRICARE [160005]","HB NWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","99.33","99.33","99.33","1 through 10","99.34","460.63","other","Tricare OPPS"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.48","44.45","","472.04","472.04","472.04","1 through 10","99.34","460.63","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.48","44.45","","279.74","279.74","279.74","1 through 10","99.34","460.63","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","631.00","473.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","374.18","59.3","","359.80","359.80","359.80","13","110.42","495.02","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","495.02","78.45","","472.04","279.74","472.04","1 through 10","110.42","495.02","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","outpatient","","","782.00","586.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","450.76","450.76","450.76","1 through 10","112.51","613.48","other","Multiple Imaging"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","700.82","175.20","700.82","1 through 10","119.97","423.04","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","318.00","238.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","117.60","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","181.07","181.07","181.07","1 through 10","159","283.67","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","237.56","50.23","237.56","1 through 10","159","283.67","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","20","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","423.04","423.04","423.04","1 through 10","112.51","557.72","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","112.51","557.72","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","141.20","135.57","282.40","74","112.51","557.72","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","212","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","557.72","73","","353.60","216.37","353.60","1 through 10","112.51","557.72","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","112.51","557.72","other","Tricare OPPS"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","557.72","other","Tricare OPPS"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","125.76","20","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.60","44.45","","338.51","338.51","571.22","1 through 10","112.51","557.72","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.24","123.76","126.29","20","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.60","44.45","","338.51","338.51","338.51","1 through 10","112.51","557.72","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","421.28","421.28","743.00","21","112.51","599.36","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","440.67","364","112.51","599.36","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","905","112.51","599.36","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.05","59.3","","435.40","435.40","435.40","146","112.51","599.36","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","128.26","128.26","384.78","50","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","282.40","134.45","320.65","42","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","129.39","258.77","1 through 10","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","599.36","78.45","","571.22","571.22","571.22","1 through 10","112.51","599.36","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","571.22","571.22","571.22","1 through 10","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","599.36","78.45","","571.22","338.51","571.22","162","112.51","599.36","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","30","112.51","474.5","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","117.59","126.29","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.93","44.45","","485.88","485.88","485.88","1 through 10","112.51","474.5","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","374.84","199.42","374.84","22","112.51","509.93","other","Multiple Imaging"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","80","112.51","509.93","other","Multiple Imaging"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","385.45","59.3","","370.35","361.50","1296.81","30","112.51","509.93","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","27","112.51","509.93","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","271.15","268.90","282.40","1 through 10","112.51","509.93","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","509.93","78.45","","485.88","485.88","485.88","17","112.51","509.93","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","271.00","203.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","157.18","58","","204.11","204.11","204.11","1 through 10","143.63","231.74","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","271.00","203.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","169.38","62.5","","674.76","218.41","674.76","1 through 10","143.63","231.74","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","outpatient","","","271.00","203.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.70","59.3","","154.70","154.70","154.70","1 through 10","120.46","212.6","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","outpatient","","","271.00","203.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","212.60","78.45","","202.96","202.96","202.96","1 through 10","120.46","212.6","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","AETNA [1001]","HB CH AETNA HMO / PPO","437.83","58.3","","413.91","372.30","413.91","17","112.51","548.23","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","423.04","423.04","423.04","1 through 10","112.51","548.23","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","548.23","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","67","112.51","548.23","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","548.23","73","","315.73","315.73","315.73","1 through 10","112.51","548.23","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","252.58","126.29","730.00","1 through 10","112.51","548.23","other","Tricare OPPS"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","432.96","223","112.51","589.16","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","612","112.51","589.16","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","445.34","59.3","","427.78","427.78","552.01","106","112.51","589.16","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","436.15","","Case rate ($436.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1130.40","1130.40","1130.40","1 through 10","112.51","589.16","other","Multiple Imaging Pregnancy Ultrasound"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","123","112.51","589.16","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","258.77","320.65","68","112.51","589.16","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","589.16","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.82","44.45","","561.22","332.59","561.22","1 through 10","112.51","589.16","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","589.16","78.45","","561.22","332.59","561.22","101","112.51","589.16","percent of total billed charges",""
"US Pregnancy >14 Weeks Ea Add","PX-40000041","CDM","76810","CPT","0402","RC","","","","both","","","583.00","437.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","","","Case rate ($0). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","104.18","104.18","104.18","1 through 10","291.5","457.36","other","Multiple Radiology standard_charge|negotiated_dollar calculated as 0;"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","877.00","657.75","AETNA [1001]","HB CH AETNA HMO / PPO","511.29","58.3","","483.65","483.65","483.65","1 through 10","112.51","640.21","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","877.00","657.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","248.34","617.92","20","112.51","640.21","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","25","112.51","688.01","other","Multiple Imaging"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","81","112.51","688.01","other","Multiple Imaging"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","520.06","59.3","","499.86","499.86","499.86","16","112.51","688.01","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","17","112.51","688.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","320.65","258.77","320.65","1 through 10","112.51","688.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","688.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","688.01","78.45","","388.63","388.63","655.79","11","112.51","688.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","904.00","678.00","AETNA [1001]","HB CH AETNA HMO / PPO","527.03","58.3","","498.39","498.39","498.39","1 through 10","360.14","659.92","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","904.00","678.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","","","Case rate ($0). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","245.15","245.15","245.15","1 through 10","360.14","659.92","other","Multiple Radiology standard_charge|negotiated_dollar calculated as 0;"
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","904.00","678.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","524.32","58","","666.73","666.73","666.73","1 through 10","360.14","659.92","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","904.00","678.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","550.54","60.9","","713.45","713.45","713.45","1 through 10","360.14","659.92","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","904.00","678.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","565.00","62.5","","734.72","734.72","734.72","1 through 10","360.14","659.92","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","outpatient","","","904.00","678.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","536.07","59.3","","515.09","515.09","515.09","1 through 10","401.83","709.19","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","outpatient","","","904.00","678.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","709.19","78.45","","675.78","400.47","675.78","1 through 10","401.83","709.19","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","611.79","611.79","611.79","18","230.56","810.3","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","632.29","632.29","632.29","106","230.56","810.3","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","810.3","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","522.10","578.71","48","230.56","810.3","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","230.56","810.3","other","OPPS APC"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","611.79","476.42","611.79","1 through 10","230.56","810.3","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","TRICARE [160005]","HB NWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","230.56","810.3","other","Tricare OPPS"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","829.54","829.53","829.54","1 through 10","230.56","810.3","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","491.59","491.59","491.59","1 through 10","230.56","810.3","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","408.67","","Case rate ($408.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","408.67","408.67","639.95","223","230.56","870.8","other","Multiple Imaging"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","408.67","","Case rate ($408.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","408.67","408.67","408.67","631","230.56","870.8","other","Multiple Imaging"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","124","230.56","870.8","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","530.29","657.10","66","230.56","870.8","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","530.29","530.29","530.29","1 through 10","230.56","870.8","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","829.54","491.59","829.54","115","230.56","870.8","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","AETNA [1001]","HB CH AETNA HMO / PPO","413.93","58.3","","391.23","391.23","391.23","71","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","22","112.51","518.3","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","141.20","564.80","184","112.51","518.3","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","518.30","73","","151.52","106.74","391.23","1 through 10","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","86.06","126.29","1 through 10","112.51","518.3","other","Tricare OPPS"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.60","44.45","","530.47","314.36","530.47","1 through 10","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.60","44.45","","314.36","314.36","314.36","1 through 10","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","271.15","141.20","271.15","1 through 10","112.51","518.3","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.03","59.3","","404.34","404.34","404.34","403","112.51","557","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","CIGNA ALTERNATE [1018]","HB CH TUFTS CIGNA CARELINK HYBRID","283.67","","Case rate ($283.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","137.04","137.04","137.04","1 through 10","112.51","557","other","Multiple Imaging Pregnancy Ultrasound"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","513.04","528","112.51","557","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","241.46","517.54","284","112.51","557","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","129.39","258.77","15","112.51","557","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.00","78.45","","530.47","314.36","530.47","383","112.51","557","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","557","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","534.00","400.50","AETNA [1001]","HB CH AETNA HMO / PPO","311.32","58.3","","294.27","294.27","294.27","1 through 10","112.51","389.82","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","534.00","400.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","389.82","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","534.00","400.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","109.79","282.40","34","112.51","389.82","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.36","44.45","","399.01","399.01","399.01","1 through 10","112.51","389.82","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.66","59.3","","304.13","304.13","304.13","44","112.51","418.92","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","30","112.51","418.92","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","160.33","320.65","17","112.51","418.92","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","282.40","271.15","282.40","1 through 10","112.51","418.92","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.92","78.45","","399.01","236.46","399.01","47","112.51","418.92","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","326.00","244.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.32","59.3","","185.76","185.76","185.76","1 through 10","163","255.75","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","326.00","244.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","189.08","58","","101.44","101.44","101.44","1 through 10","163","255.75","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","326.00","244.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","203.75","62.5","","111.79","111.79","111.79","1 through 10","163","255.75","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","255.75","78.45","","243.71","243.71","243.71","1 through 10","163","255.75","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","AETNA [1001]","HB CH AETNA HMO / PPO","419.18","58.3","","396.33","396.33","396.33","14","119.97","524.87","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","524.87","73","","108.14","108.14","108.14","1 through 10","119.97","524.87","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","699.00","699.00","699.00","1 through 10","119.97","524.87","other","Tricare OPPS"
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.60","44.45","","537.39","318.46","537.39","1 through 10","119.97","524.87","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.60","44.45","","318.46","318.46","318.46","1 through 10","119.97","524.87","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","719.00","539.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.37","59.3","","409.61","409.61","409.61","111","199.42","564.06","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","719.00","539.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.06","78.45","","537.39","318.46","537.39","118","199.42","564.06","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","AETNA [1001]","HB CH AETNA HMO / PPO","350.97","58.3","","331.70","298.35","331.70","13","112.51","439.46","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","211.52","211.52","211.52","1 through 10","112.51","439.46","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.33","154.14","160.33","1 through 10","112.51","439.46","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","141.20","70.60","282.40","50","112.51","439.46","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","439.46","73","","90.50","90.50","90.50","1 through 10","112.51","439.46","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.59","44.45","","449.75","449.75","449.75","1 through 10","112.51","439.46","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","439.46","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","173.48","99.71","346.96","157","112.51","472.27","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","472.27","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","199.42","454","112.51","472.27","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","356.99","59.3","","342.81","342.81","342.81","46","112.51","472.27","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","128.26","128.26","256.52","69","112.51","472.27","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","134.45","134.45","403.35","56","112.51","472.27","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","129.39","129.39","258.77","1 through 10","112.51","472.27","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","472.27","78.45","","449.75","266.53","449.75","65","112.51","472.27","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","39","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","FALLON HEALTH [1008]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","371.28","371.28","371.28","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","423.04","1 through 10","112.51","580.35","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","25","112.51","580.35","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","510","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","564.29","564.29","564.29","1 through 10","112.51","580.35","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","580.35","other","Tricare OPPS"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","377.28","57","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","594.28","594.28","594.28","1 through 10","112.51","580.35","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","31","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","438.29","353.11","438.29","1 through 10","112.51","623.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","458.47","117","112.51","623.68","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","290","112.51","623.68","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","452.98","452.98","452.98","55","112.51","623.68","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","110","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","258.77","320.65","54","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","594.28","352.18","594.28","38","112.51","623.68","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","564.80","1 through 10","112.51","548.96","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","548.96","73","","533.63","414.48","533.63","1 through 10","112.51","548.96","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","548.96","other","Tricare OPPS"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.26","44.45","","561.99","561.99","561.99","1 through 10","112.51","548.96","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","414.48","414.48","414.48","1 through 10","112.51","589.94","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","433.56","20","112.51","589.94","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","70","112.51","589.94","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","445.94","59.3","","428.37","428.37","428.37","1 through 10","112.51","589.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","21","112.51","589.94","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","258.77","320.65","1 through 10","112.51","589.94","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","589.94","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","589.94","78.45","","561.99","333.04","561.99","1 through 10","112.51","589.94","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","AETNA [1001]","HB CH AETNA HMO / PPO","410.43","58.3","","388.40","388.40","388.40","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","36","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","112.51","513.92","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","36","112.51","513.92","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","HUMANA [1012]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","124.77","124.77","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","427","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","513.92","73","","401.41","388.40","401.41","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","112.51","513.92","other","Tricare OPPS"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","513.92","other","Tricare OPPS"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","59","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.93","44.45","","312.09","312.09","526.63","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","35","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.93","44.45","","306.30","306.30","306.30","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","406.27","198","112.51","552.29","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","410","112.51","552.29","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","417.47","59.3","","401.41","401.41","401.41","91","112.51","552.29","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","142","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","320.65","81","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","552.29","78.45","","526.63","312.09","526.63","72","112.51","552.29","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","both","","","658.00","493.50","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","480.34","other","Tricare OPPS"
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","both","","","658.00","493.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.48","44.45","","492.03","492.03","492.03","1 through 10","119.97","480.34","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","658.00","493.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","390.19","59.3","","375.04","375.04","375.04","1 through 10","199.42","516.2","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","MEDICARE [2001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2165.00","1623.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1283.85","59.3","","1233.53","1233.53","1233.53","1 through 10","40.35","1698.44","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","MEDICARE [2001]","HB NWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","2165.00","1623.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1283.85","59.3","","1233.53","1233.53","1233.53","1 through 10","40.35","1698.44","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","AETNA [1001]","HB CH AETNA HMO / PPO","334.64","58.3","","316.39","316.39","316.39","22","112.51","419.02","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","21","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","CHAMPVA [160001]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","419.02","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","211.52","211.52","211.52","1 through 10","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.33","160.33","320.65","12","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","141.20","282.40","93","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","234","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","419.02","73","","316.39","162.50","316.39","1 through 10","112.51","419.02","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","112.51","419.02","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","112.51","419.02","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","19","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.14","44.45","","254.22","254.22","428.99","12","112.51","419.02","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","22","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.14","44.45","","428.99","254.22","428.99","1 through 10","112.51","419.02","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","271.15","271.15","271.15","1 through 10","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","199.42","422","112.51","450.3","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","199.42","1091","112.51","450.3","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","340.38","59.3","","326.99","326.99","326.99","187","112.51","450.3","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","739.20","353","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","160.33","320.65","169","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","129.39","129.39","258.77","1 through 10","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","450.30","78.45","","428.99","428.99","428.99","1 through 10","112.51","450.3","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","428.99","428.99","428.99","1 through 10","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","450.30","78.45","","428.99","254.22","428.99","184","112.51","450.3","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","209.95","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","14.12","173.37","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","215.00","1 through 10","14.12","173.37","percent of total billed charges",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","55225.70","41419.27","MEDICARE [2001]","HB NWH MEDICARE","15896.57","","Case rate ($15,896.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,330.10, add-ons for qualifying new technology services are included. If operating cost exceeds $61,472.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,156.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,681.77. The transfer operating threshold is the transfer adjustment factor * $16,330.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,214.80. The transfer capital threshold is the transfer adjustment factor * $1,214.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17434.34","17434.34","17434.34","1 through 10","15578.64","18834.22","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","55225.70","41419.27","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","15578.64","","Case rate ($15,896.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,330.10, add-ons for qualifying new technology services are included. If operating cost exceeds $61,472.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,156.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,681.77. The transfer operating threshold is the transfer adjustment factor * $16,330.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,214.80. The transfer capital threshold is the transfer adjustment factor * $1,214.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15578.57","15578.57","15578.57","1 through 10","15578.64","18834.22","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","56351.84","42263.88","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","10534.35","","Case rate ($10,749.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $11,042.49, add-ons for qualifying new technology services are included. If operating cost exceeds $56,184.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,763.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $9,927.88. The transfer operating threshold is the transfer adjustment factor * $11,042.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $821.45. The transfer capital threshold is the transfer adjustment factor * $821.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10226.73","10226.73","10226.73","1 through 10","10534.35","11853.9443","other","Inpatient DRG"
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","32453.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17611.58","","Standard inlier is a Case rate ($17,611.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,500.03) for the length of stay and the standard reimbursement.","23513.48","23513.48","23513.48","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","32453.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18918.35","","Standard inlier is a Case rate ($18,918.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,685.38) for the length of stay and the standard reimbursement.","18918.34","18058.42","18918.34","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","32453.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9567.7632","","Fee schedule rate ($12,983.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9567.7632","24071.84","24071.84","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","32453.37","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10046.1024","","Fee schedule rate ($13,632.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10046.1024","25275.32","25275.32","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","21977.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10494.87","","Standard inlier is a Case rate ($10,494.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,489.79) for the length of stay and the standard reimbursement.","10017.96","10017.96","10494.87","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","21977.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11273.59","","Standard inlier is a Case rate ($11,273.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,600.24) for the length of stay and the standard reimbursement.","10761.14","10761.14","11273.58","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","21977.58","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11091.94","","Fee schedule rate ($11,091.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10118.56","10118.56","10118.56","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","26097.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11938.81","","Standard inlier is a Case rate ($11,938.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,897, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,694.76) for the length of stay and the standard reimbursement.","11938.80","11396.28","11938.80","16","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","26097.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12824.66","","Standard inlier is a Case rate ($12,824.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,897, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,820.41) for the length of stay and the standard reimbursement.","12824.65","12241.71","12824.65","50","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","26097.86","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","12604.33","","Fee schedule rate ($12,604.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14006.44","14006.44","14006.44","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","26097.86","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","4867.60","","Fee schedule rate ($4,867.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4867.60","4867.60","4867.60","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","26097.86","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9881.43","","Fee schedule rate ($9,881.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9881.43","9881.43","9881.43","1 through 10","3473.74","43443.2","case rate",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","26184.04","19638.03","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11712.03","11712.03","11712.03","1 through 10","9098.57","10999.97","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","33355.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17611.58","","Standard inlier is a Case rate ($17,611.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,500.03) for the length of stay and the standard reimbursement.","13537.18","13537.18","13537.18","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","33355.36","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","7108.00","","Per diem ($7,108). If length of stay < 3, first 1 days paid at a per diem of $14,216 instead.","21324.04","21324.04","21324.04","1 through 10","2213","23157.64","per diem","Estimated amount calculated based on 2 day length of stay."
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","23484.08","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9777.81","","Standard inlier is a Case rate ($9,777.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,387.92) for the length of stay and the standard reimbursement.","17182.93","17182.93","17182.93","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","23484.08","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13128.3156","","Fee schedule rate ($13,128.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13128.3156","13128.32","13128.32","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","23484.08","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13784.6642","","Fee schedule rate ($13,784.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13784.6642","13784.68","13784.68","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","23484.08","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","14441.01","","Fee schedule rate ($14,441.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10163.32","10163.32","10163.32","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","23484.08","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","6338.81","","Fee schedule rate ($6,338.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6338.81","6338.81","6338.81","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10394.36","","Standard inlier is a Case rate ($10,394.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,475.52) for the length of stay and the standard reimbursement.","19912.68","19912.68","19912.68","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11165.62","","Standard inlier is a Case rate ($11,165.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $22,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,584.91) for the length of stay and the standard reimbursement.","17093.16","17093.16","17093.16","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13128.3156","","Fee schedule rate ($14,035.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13128.3156","14035.06","42237.84","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13784.6642","","Fee schedule rate ($14,736.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13784.6642","28482.59","28482.59","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","15438.43","","Fee schedule rate ($15,438.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15438.44","15438.44","15438.44","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","5410.70","","Fee schedule rate ($5,410.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5410.66","5410.66","5410.66","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","6683.48","","Fee schedule rate ($6,683.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6683.48","6683.48","6683.48","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","26716.72","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","13567.73","","Fee schedule rate ($13,567.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13567.73","13567.73","13567.73","1 through 10","2213","23157.64","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","24110.34","18082.75","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7460.06","6650.63","9551.50","16","6401.95","7739.81","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","26350.53","19762.90","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7460.06","7460.06","9551.50","1 through 10","9163.11","11077.99","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","22471.49","16853.62","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","6016.45","","Case rate ($5,841.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,000.52, add-ons for qualifying new technology services are included. If operating cost exceeds $51,142.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,388.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,394.84. The transfer operating threshold is the transfer adjustment factor * $6,000.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.38. The transfer capital threshold is the transfer adjustment factor * $446.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5719.72","5719.72","5719.72","1 through 10","5724.39","6920.66","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","22471.49","16853.62","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6650.63","6650.63","7460.06","37","5724.39","6920.66","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","22471.49","16853.62","MEDICARE [2001]","HB NWH MEDICARE","5841.21","","Case rate ($5,841.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $6,000.52, add-ons for qualifying new technology services are included. If operating cost exceeds $51,142.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,388.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,394.84. The transfer operating threshold is the transfer adjustment factor * $6,000.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.38. The transfer capital threshold is the transfer adjustment factor * $446.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6093.44","6093.44","6093.44","1 through 10","5724.39","6920.66","other","Inpatient Replacement Plans DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","TRIS-DRG","","","","","","","","inpatient","","","22859.66","","CHAMPVA [160001]","HB NWH TRICARE","3230.63","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($4,529.52). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,350.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,529.52), capped at $4,084.33. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,350.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","5759.49","5759.49","5759.49","1 through 10","3230.63","3230.63","other","Inpatient DRGs"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","TRIS-DRG","","","","","","","","inpatient","","","22859.66","","TRICARE [160005]","HB NWH TRICARE","3230.63","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($4,529.52). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,350.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,529.52), capped at $4,084.33. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.366 that exceeds an outlier threshold of $48,350.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","4716.83","153.04","5235.89","12","3230.63","3230.63","other","Inpatient DRGs"
"Vaginal Delivery,EXTREME","560","DRG","","","","","","","","inpatient","","","26391.43","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","26485.22","","Fee schedule rate ($26,485.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26485.24","26485.24","26485.24","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13537.18","","Standard inlier is a Case rate ($13,537.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,536, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,921.66) for the length of stay and the standard reimbursement.","13537.18","12922.03","13537.18","17","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14541.63","","Standard inlier is a Case rate ($14,541.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,536, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,064.12) for the length of stay and the standard reimbursement.","14541.63","13880.65","14541.63","42","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($12,983.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","12483.42","12983.70","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($13,632.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","13632.84","13632.84","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","14281.94","","Fee schedule rate ($14,281.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14281.96","14281.96","14281.96","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","MASSHEALTH [3001]","HB NWH MEDICAID","8843.06","","Case rate ($9,527). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,957, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9551.49","9551.49","9551.49","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5522.72","","Fee schedule rate ($5,522.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5522.72","5522.72","5522.72","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","27987.90","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","11771.41","","Fee schedule rate ($11,771.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11771.41","11771.41","11771.41","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9102.42","","Standard inlier is a Case rate ($9,102.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,292.12) for the length of stay and the standard reimbursement.","9102.41","8688.79","9102.41","131","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9777.81","","Standard inlier is a Case rate ($9,777.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,387.92) for the length of stay and the standard reimbursement.","9777.81","9333.36","9777.81","391","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($9,239.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","9239.46","9239.46","50","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($9,701.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","9701.40","10163.31","39","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","11549.09","","Fee schedule rate ($11,549.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11549.09","11549.09","11549.09","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","10163.31","","Fee schedule rate ($10,163.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10163.31","9771.36","10163.32","22","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","9701.38","","Fee schedule rate ($9,701.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.38","9701.38","9701.38","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","MASSHEALTH [3001]","HB NWH MEDICAID","6157.35","","Case rate ($6,633.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,063.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6650.64","6650.64","6650.64","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","3090.88","","Fee schedule rate ($3,090.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3090.85","3090.85","3090.85","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","3636.30","","Fee schedule rate ($3,636.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3636.30","3000.75","3636.30","20","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","3817.95","","Fee schedule rate ($3,817.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3636.30","3636.30","3636.30","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","7750.60","","Fee schedule rate ($7,750.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7750.60","7750.60","7750.60","53","3090.88","39727.83","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","22129.10","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","6157.35","","Case rate ($6,633.58). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $49,063.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6650.63","6650.63","6650.63","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11938.81","","Standard inlier is a Case rate ($11,938.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,897, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,694.76) for the length of stay and the standard reimbursement.","10394.36","9922.02","10394.36","115","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12824.66","","Standard inlier is a Case rate ($12,824.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $23,897, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,820.41) for the length of stay and the standard reimbursement.","11165.61","10658.08","11165.61","245","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9239.4576","","Fee schedule rate ($10,083.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9239.4576","9695.12","10083.68","61","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($10,587.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","10179.64","11091.94","50","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","12604.33","","Fee schedule rate ($12,604.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12604.33","12604.33","12604.33","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","11091.94","","Fee schedule rate ($11,091.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11091.92","10664.17","11091.94","29","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","10587.80","","Fee schedule rate ($10,587.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10587.80","10587.80","10587.80","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","MASSHEALTH [3001]","HB NWH MEDICAID","8169.06","","Case rate ($8,800.87). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,230.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7460.07","341.71","7460.07","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","3940.64","","Fee schedule rate ($3,940.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3332.31","3332.31","3332.31","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","4636.01","","Fee schedule rate ($4,636.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3920.36","3920.36","3920.36","15","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL PPO","4867.60","","Fee schedule rate ($4,867.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3920.36","3920.36","3920.36","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","9881.43","","Fee schedule rate ($9,881.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8356.06","8112.75","8356.06","37","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","9701.3832","","Fee schedule rate ($10,587.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9701.3832","10664.17","10664.17","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","10163.3088","","Fee schedule rate ($11,091.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10163.3088","11091.94","11091.94","1 through 10","3090.88","39727.83","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","23629.60","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","8169.06","","Case rate ($8,800.87). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $51,230.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7460.06","7460.06","7460.06","1 through 10","3090.88","39727.83","case rate",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","1 through 10","13.27","141.55","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","84.97","84.97","84.97","1 through 10","13.98","116.89","percent of total billed charges",""
"Vanillylmandelic Acid (Vma) Urine","PX-30000731","CDM","84585","CPT","0301","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","15.19","122.55","percent of total billed charges",""
"Vanillylmandelic Acid (Vma) Urine","PX-30000731","CDM","84585","CPT","0301","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","96.10","96.10","96.10","1 through 10","15.99","101.2","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","51","12.62","143.45","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.12","44.45","","113.01","113.01","113.01","1 through 10","12.62","143.45","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","258.42","53","13.29","118.46","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","66.97","178.13","32","13.29","118.46","percent of total billed charges",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","32176.00","24132.00","MEDICARE [2001]","HB NWH MEDICARE","21322.53","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","21324.68","21324.68","21324.68","1 through 10","8702.14","25068.32","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","32176.00","24132.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,383). Procedure 2, Per diem ($2,691.50). Procedures 3 - 9999, Per diem ($1,345.75).","8884.20","8884.20","8884.20","1 through 10","8702.14","25068.32","per diem",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","32176.00","24132.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","20896.08","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20983.49","20898.19","20983.49","1 through 10","8702.14","25068.32","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","32176.00","24132.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","15634.74","15634.74","15634.74","1 through 10","8702.14","25242.07","other","ASC "
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","32176.00","24132.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","15988.57","15656.85","15988.57","1 through 10","8702.14","25242.07","other","ASC "
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","32176.00","24132.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","20450.03","20450.03","20450.03","1 through 10","8702.14","25242.07","other","Multiple Surgery"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","both","","","30555.00","22916.25","MEDICARE [2001]","HB NWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","13467.61","13467.61","1 through 10","8702.14","23805.4","other","OPPS APC"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","both","","","30555.00","22916.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13198.26","13198.26","13198.26","1 through 10","8702.14","23805.4","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","22341.00","16755.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13252.13","13252.13","13252.13","1 through 10","8702.14","17405.87","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","22341.00","16755.75","MEDICARE [2001]","HB NWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","13467.61","24013.82","1 through 10","8702.14","17405.87","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","22341.00","16755.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,934). Procedure 2, Per diem ($2,967). Procedures 3 - 9999, Per diem ($1,483.50).","5934.00","5934.00","5934.00","1 through 10","8702.14","17405.87","per diem",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","22341.00","16755.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","15988.57","15656.85","15988.57","1 through 10","8702.14","17526.51","other","ASC "
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","29746.00","22309.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","15634.74","15634.74","15634.74","1 through 10","4472.66","23335.74","other","ASC "
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","29746.00","22309.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","15988.57","15656.85","15988.57","1 through 10","4472.66","23335.74","other","ASC "
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","29746.00","22309.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","39333.68","39333.68","39333.68","1 through 10","4472.66","23335.74","other","Multiple Surgery"
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","33","16.92","147.25","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","113.15","73","","85.62","85.62","85.62","1 through 10","16.92","147.25","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB NWH TRICARE","147.25","95","","20.81","20.81","20.81","1 through 10","16.92","147.25","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","116.09","68.80","116.09","1 through 10","16.92","147.25","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","68.80","68.80","68.80","1 through 10","16.92","147.25","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","265.47","48","13.35","121.6","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","68.80","116.09","29","13.35","121.6","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","4872.00","3654.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1408.57","1408.57","1408.57","1 through 10","1565.78","3822.08","other","ASC "
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","4872.00","3654.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2889.10","59.3","","1387.94","1387.94","1387.94","1 through 10","1565.78","3822.08","percent of total billed charges",""
"Vasoactive Intestinal Peptide (Vip)","PX-30000732","CDM","84586","CPT","0301","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","19.68","139.64","percent of total billed charges",""
"Vasopressin (Adh)","PX-30000733","CDM","84588","CPT","0301","RC","","","","both","","","295.00","221.25","AETNA [1001]","HB CH AETNA HMO / PPO","171.99","58.3","","162.73","162.73","162.73","1 through 10","33.26","280.25","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","355.00","266.25","AETNA [1001]","HB CH AETNA HMO / PPO","206.97","58.3","","121.91","121.91","121.91","1 through 10","18.27","337.25","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.52","59.3","","125.99","125.99","125.99","1 through 10","14.12","278.5","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.50","78.45","","165.29","97.95","215.00","1 through 10","14.12","278.5","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","both","","","2715.00","2036.25","AETNA [1001]","HB CH AETNA HMO / PPO","1582.85","58.3","","1496.88","1496.88","1496.88","1 through 10","351.32","2115.26","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","both","","","2715.00","2036.25","MEDICARE [2001]","HB NWH MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","2115.26","other","OPPS APC"
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","AETNA [1001]","HB CH AETNA HMO / PPO","9.33","58.3","","9.07","9.07","9.07","625","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CHAMPVA [160001]","HB NWH TRICARE","15.20","95","","8.83","8.83","19.28","1 through 10","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","11.68","73","","11.68","11.68","11.68","1 through 10","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","9.33","58.3","","9.07","9.07","9.07","1 through 10","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","8.48","53","","8.48","8.48","8.48","1 through 10","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","11.68","73","","9.07","2.85","11.68","37","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","TRICARE [160005]","HB NWH TRICARE","15.20","95","","8.83","8.64","9.09","109","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","TUFTS HEALTH PLAN [170001]","HB NWH TRICARE","15.20","95","","9.09","9.09","9.09","1 through 10","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.11","44.45","","12.30","7.29","12.30","133","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.11","44.45","","7.29","7.29","12.30","23","7.11","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","inpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.30","70.6","","12.30","7.29","12.30","1 through 10","8.96","11.3","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","9.49","59.3","","9.38","9.38","9.38","216","8","12.75","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","12.55","78.45","","12.30","12.30","12.30","1 through 10","8","12.75","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","12.55","78.45","","12.30","7.29","12.30","3891","8","12.75","percent of total billed charges",""
"Venous Blood Collection SNF/Hha","PX-30003517","CDM","G0471","HCPCS","0300","RC","","","","both","","","40.00","30.00","WELLPOINT [1015]","HB CH WELLPOINT","31.16","77.91","","30.72","30.72","30.72","1 through 10","10.87","38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4392.00","3294.00","AETNA [1001]","HB CH AETNA HMO / PPO","2560.54","58.3","","2421.66","2421.66","2421.66","1 through 10","1952.24","3888.77","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4392.00","3294.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,218). Procedure 2, Per diem ($1,609). Procedures 3 - 9999, Per diem ($804.50).","2733.44","2733.44","2733.44","1 through 10","1952.24","3888.77","per diem",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4392.00","3294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1952.24","44.45","","3283.54","3283.54","3283.54","1 through 10","1952.24","3888.77","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","1 through 10","2125.14","7461","other","ASC "
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","14","2125.14","7461","other","ASC "
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2604.46","59.3","","2502.81","2502.81","2502.81","1 through 10","2125.14","7461","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","7461","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5249.10","5249.10","5249.10","1 through 10","2125.14","7461","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4392.00","3294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3445.52","78.45","","3283.54","3283.54","3283.54","1 through 10","2125.14","7461","percent of total billed charges",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","52055.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","53879.36","","Fee schedule rate ($53,879.36). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($6,234.16) multiplied by length of stay and the outlier percent (100%).","53879.36","53879.36","53879.36","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","52055.35","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46975.24","","Fee schedule rate ($46,975.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45607.45","45607.45","45607.45","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","45831.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26584.07","","Standard inlier is a Case rate ($26,584.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,773.71) for the length of stay and the standard reimbursement.","26584.06","26584.06","26584.06","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","45831.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28556.59","","Standard inlier is a Case rate ($28,556.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,053.49) for the length of stay and the standard reimbursement.","27258.56","27258.56","27258.56","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","45831.29","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16573.5702","","Fee schedule rate ($23,774.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16573.5702","16573.58","16573.58","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","49258.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35840.93","","Standard inlier is a Case rate ($35,840.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,087.76) for the length of stay and the standard reimbursement.","34212.26","34212.26","34212.26","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","49258.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38500.31","","Standard inlier is a Case rate ($38,500.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $48,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,464.96) for the length of stay and the standard reimbursement.","38500.30","38500.30","38500.30","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","49258.26","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16573.5702","","Fee schedule rate ($23,774.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16573.5702","22858.70","22858.70","1 through 10","9727.25","72439.37","case rate",""
"Vertigo And Other Labyrinth Disorders,MAJOR","111","DRG","","","","","","","","inpatient","","","40388.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18141.10","","Standard inlier is a Case rate ($18,141.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $30,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,575.20) for the length of stay and the standard reimbursement.","39587.24","39587.24","39587.24","1 through 10","3854.34","23709.01","case rate",""
"Vertigo And Other Labyrinth Disorders,MINOR","111","DRG","","","","","","","","inpatient","","","41205.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14049.19","","Standard inlier is a Case rate ($14,049.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $25,064, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,994.22) for the length of stay and the standard reimbursement.","14049.18","14049.18","14049.18","1 through 10","3854.34","23709.01","case rate",""
"VEST SUPPORT SIZE 1 MAMMARY NYLON ZIPPER FRONT ADJUSTABLE VELCRO STRAP DUAL CUP WASHABLE","SUP-ITM-10016186","CDM","L0625","HCPCS","0274","RC","","","","both","","","141.12","105.84","AETNA [1001]","HB CH AETNA HMO / PPO","82.27","58.3","","80.02","80.02","80.02","1 through 10","40.84","153.26","percent of total billed charges",""
"VEST SUPPORT SIZE 1 MAMMARY NYLON ZIPPER FRONT ADJUSTABLE VELCRO STRAP DUAL CUP WASHABLE","SUP-ITM-10016186","CDM","L0625","HCPCS","0274","RC","","","","both","","","141.12","105.84","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","81.43","57.7","","170.19","170.19","170.19","1 through 10","40.84","153.26","percent of total billed charges",""
"VEST SUPPORT SIZE 1 MAMMARY NYLON ZIPPER FRONT ADJUSTABLE VELCRO STRAP DUAL CUP WASHABLE","SUP-ITM-10016186","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","141.12","105.84","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","81.43","57.7","","170.19","170.19","170.19","1 through 10","62.73","137.08","percent of total billed charges",""
"VEST SUPPORT SIZE 1 MAMMARY NYLON ZIPPER FRONT ADJUSTABLE VELCRO STRAP DUAL CUP WASHABLE","SUP-ITM-10016186","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","141.12","105.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.71","78.45","","249.61","249.61","249.61","1 through 10","62.73","137.08","percent of total billed charges",""
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","9.87","147.35","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","9.87","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","18.14","18.14","18.14","1 through 10","10.22","147.35","percent of total billed charges",""
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","51.85","155.55","21","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","23","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.82","53.70","17","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.04","78.45","","24.27","14.58","24.27","1 through 10","11.5","100.34","percent of total billed charges",""
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","12.19","147.35","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","12.19","147.35","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","50.81","161.07","1 through 10","12.19","147.35","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.81","54.79","1 through 10","12.19","147.35","other","OPPS APC"
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","16.44","16.44","16.44","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14.38","62.5","","29.00","29.00","29.00","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","18.14","18.14","18.14","77","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CHAMPVA [160001]","HB NWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","32.00","32.00","32.00","1 through 10","10.22","232.43","other","Tricare OPPS"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.64","59.3","","18.75","18.75","18.75","111","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","13.64","59.3","","18.30","18.30","18.30","1 through 10","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","23","10.22","232.43","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.79","73","","18.30","18.14","18.30","1 through 10","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TRICARE [160005]","HB NWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","84.52","84.52","84.52","1 through 10","10.22","232.43","other","Tricare OPPS"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.22","44.45","","24.60","14.37","24.60","1 through 10","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB CH WELLPOINT","17.92","77.91","","25.20","25.20","57.20","27","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.04","78.45","","24.60","14.58","96.00","108","11.5","154.78","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","16.44","16.44","16.45","18","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","13.34","58","","29.00","29.00","29.00","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","13.34","58","","29.00","29.00","29.00","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","14.38","62.5","","29.00","29.00","29.00","15","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.79","73","","16.44","16.44","16.44","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB CH WELLPOINT","17.92","77.91","","51.84","22.84","51.84","1 through 10","12.19","17.92","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.64","59.3","","16.99","16.99","17.00","13","10.22","18.04","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.04","78.45","","29.00","22.30","29.00","17","10.22","18.04","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","125.31","125.31","125.31","71","10.22","232.43","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","43.67","43.67","87.33","36","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","41.59","83.17","144","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","FALLON HEALTH [1008]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.90","82.90","82.90","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB NWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42.26","42.26","84.52","1435","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.42","82.83","133","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.22","44.45","","100.69","100.69","100.69","11","10.22","232.43","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","42.26","84.52","38","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.64","59.3","","129.51","129.51","129.51","63","11.5","204.65","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.04","78.45","","169.90","100.69","169.91","19","11.5","204.65","percent of total billed charges",""
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","27218.34","20413.75","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","13370.59","","Case rate ($12,981.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,335.18, add-ons for qualifying new technology services are included. If operating cost exceeds $58,477.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,933.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,989.15. The transfer operating threshold is the transfer adjustment factor * $13,335.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.01. The transfer capital threshold is the transfer adjustment factor * $992.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13225.28","13225.28","13225.28","1 through 10","12721.54","15380.05","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","27218.34","20413.75","FALLON HEALTH [1008]","HB NWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","23327.81","23327.81","23327.81","1 through 10","12721.54","15380.05","case rate",""
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","27218.34","20413.75","MEDICARE [2001]","HB NWH MEDICARE","14273.11","","Case rate ($14,273.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $13,335.18, add-ons for qualifying new technology services are included. If operating cost exceeds $58,477.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,933.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,281.10. The transfer operating threshold is the transfer adjustment factor * $13,335.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.01. The transfer capital threshold is the transfer adjustment factor * $992.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14086.23","14086.05","14111.57","13","12721.54","15380.05","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","19046.81","14285.11","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","7760.17","","Case rate ($7,534.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,739.62, add-ons for qualifying new technology services are included. If operating cost exceeds $52,881.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,958.40. The transfer operating threshold is the transfer adjustment factor * $7,739.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.75. The transfer capital threshold is the transfer adjustment factor * $575.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7958.57","7958.57","7958.57","1 through 10","7383.47","8926.44","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","19046.81","14285.11","MEDICARE [2001]","HB NWH MEDICARE","8283.99","","Case rate ($8,283.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,739.62, add-ons for qualifying new technology services are included. If operating cost exceeds $52,881.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,708.23. The transfer operating threshold is the transfer adjustment factor * $7,739.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.75. The transfer capital threshold is the transfer adjustment factor * $575.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8444.68","8444.68","8459.86","22","7383.47","8926.44","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","19046.81","14285.11","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","7383.47","","Case rate ($7,534.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,739.62, add-ons for qualifying new technology services are included. If operating cost exceeds $52,881.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,958.40. The transfer operating threshold is the transfer adjustment factor * $7,739.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.75. The transfer capital threshold is the transfer adjustment factor * $575.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7547.86","7547.86","7547.86","1 through 10","7383.47","8926.44","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","19046.81","14285.11","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","7383.47","","Case rate ($7,534.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $7,739.62, add-ons for qualifying new technology services are included. If operating cost exceeds $52,881.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $3,517.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,958.40. The transfer operating threshold is the transfer adjustment factor * $7,739.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.75. The transfer capital threshold is the transfer adjustment factor * $575.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7575.49","7575.49","7575.49","1 through 10","7383.47","8926.44","other","Inpatient DRG"
"Viral Illness,EXTREME","723","DRG","","","","","","","","inpatient","","","39104.35","","WELLSENSE [1003]","HB NWH WELLSENSE MCO","21597.57","","Case rate ($23,267.97). If cost, defined as total billed times cost-to-charge ratio (0.4712), exceeds outlier threshold $65,697.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29159.76","29159.76","29159.76","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","21508.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13303.94","","Standard inlier is a Case rate ($13,303.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,888.44) for the length of stay and the standard reimbursement.","19058.00","19058.00","19058.00","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","21508.86","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8414.7852","","Fee schedule rate ($18,840.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8414.7852","18840.44","18840.44","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","21508.86","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8835.4814","","Fee schedule rate ($19,782.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8835.4814","19782.36","19782.36","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","21508.86","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","20803.18","","Fee schedule rate ($20,803.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20803.18","20803.18","20803.18","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MINOR","723","DRG","","","","","","","","inpatient","","","13712.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8680.76","","Standard inlier is a Case rate ($8,680.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,554, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,232.27) for the length of stay and the standard reimbursement.","8680.76","8680.76","8680.76","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MINOR","723","DRG","","","","","","","","inpatient","","","13712.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9324.87","","Standard inlier is a Case rate ($9,324.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $20,554, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,323.63) for the length of stay and the standard reimbursement.","13303.93","9324.86","13682.06","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MINOR","723","DRG","","","","","","","","inpatient","","","13712.58","","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","13524.24","","Fee schedule rate ($13,524.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.3064), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9610.47","9610.47","9610.47","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","20548.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12384.98","","Standard inlier is a Case rate ($12,384.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,758.10) for the length of stay and the standard reimbursement.","11823.02","11822.18","12384.97","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","20548.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13303.94","","Standard inlier is a Case rate ($13,303.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.3037, exceeds the outlier threshold of $24,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,888.44) for the length of stay and the standard reimbursement.","13303.93","12699.21","13303.94","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","20548.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8414.7852","","Fee schedule rate ($10,462.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8414.7852","10462.78","10462.78","1 through 10","3794.94","106124.68","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","20548.01","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8835.4814","","Fee schedule rate ($10,985.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8835.4814","10985.87","10985.87","1 through 10","3794.94","106124.68","case rate",""
"Viral Meningitis,MINOR","051","DRG","","","","","","","","inpatient","","","28593.84","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11830.7268","","Fee schedule rate ($11,830.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.606), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,410), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11830.7268","11830.72","11830.72","1 through 10","6436.55","27259.08","case rate",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","78.85","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","9.6","65.11","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","36.90","36.90","36.90","1 through 10","9.6","65.11","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001446","CDM","86790","CPT","0302","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","78.85","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001446","CDM","86790","CPT","0302","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","9.6","65.11","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001446","CDM","86790","CPT","0302","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","36.90","36.90","36.90","1 through 10","9.6","65.11","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","both","","","9.58","7.18","AETNA [1001]","HB CH AETNA HMO / PPO","5.59","58.3","","5.43","2.82","5.43","1 through 10","3.25","11.22","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","137.00","102.75","AETNA [1001]","HB CH AETNA HMO / PPO","79.87","58.3","","75.41","75.41","75.41","1 through 10","11.38","130.15","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","137.00","102.75","TRICARE [160005]","HB NWH TRICARE","130.15","95","","13.99","13.99","13.99","1 through 10","11.38","130.15","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","137.00","102.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.24","59.3","","77.94","77.94","77.94","1 through 10","11.97","107.48","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.48","78.45","","102.25","46.69","102.25","1 through 10","11.97","107.48","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0300","RC","","","","inpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.14","70.6","","76.54","76.54","76.54","1 through 10","96.88","122.14","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","95.26","95.26","95.26","375","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","122.64","122.64","122.64","1 through 10","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","89.04","89.04","89.04","1 through 10","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","118.99","13.58","118.99","1 through 10","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB NWH TRICARE","164.35","95","","18.17","18.17","18.17","1 through 10","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.90","44.45","","129.16","76.54","129.16","14","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.90","44.45","","129.16","129.16","129.16","1 through 10","14.78","164.35","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","396","15.43","135.72","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","1 through 10","15.43","135.72","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","76.54","129.16","314","15.43","135.72","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","90.72","90.72","90.72","1 through 10","19.84","156.75","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","93.76","93.76","93.76","1 through 10","20.87","129.44","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.34","44.45","","123.01","123.01","123.01","1 through 10","20.87","129.44","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","72.90","72.90","72.90","1 through 10","20.87","129.44","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","125.87","125.87","125.87","16","27.54","216.6","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","170.67","170.67","170.67","1 through 10","27.54","216.6","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","130.09","130.09","130.09","11","28.01","178.87","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","170.67","101.14","170.67","11","28.01","178.87","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","177.00","132.75","AETNA [1001]","HB CH AETNA HMO / PPO","103.19","58.3","","97.52","97.52","97.52","51","20.81","168.15","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","177.00","132.75","TRICARE [160005]","HB NWH TRICARE","168.15","95","","25.58","25.58","25.58","1 through 10","20.81","168.15","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.68","44.45","","132.23","78.36","132.23","1 through 10","20.81","168.15","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","177.00","132.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.96","59.3","","100.79","100.79","100.79","44","21.89","138.86","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.86","78.45","","132.23","78.36","132.23","35","21.89","138.86","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","84.00","63.00","AETNA [1001]","HB CH AETNA HMO / PPO","48.97","58.3","","46.49","46.49","46.49","1 through 10","9.69","79.8","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","84.00","63.00","TRICARE [160005]","HB NWH TRICARE","79.80","95","","11.92","11.92","11.92","1 through 10","9.69","79.8","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","84.00","63.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.81","59.3","","48.05","48.05","48.05","1 through 10","10.19","65.9","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","63.04","63.04","63.04","1 through 10","10.19","65.9","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","AETNA [1001]","HB CH AETNA HMO / PPO","203.47","58.3","","192.21","192.21","192.21","486","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","254.77","73","","247.47","247.47","247.47","1 through 10","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","254.77","73","","192.21","26.64","192.21","1 through 10","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","TRICARE [160005]","HB NWH TRICARE","331.55","95","","35.67","33.89","35.67","1 through 10","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.13","44.45","","260.62","154.45","260.62","25","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.13","44.45","","260.62","154.45","260.62","1 through 10","29.01","331.55","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","349.00","261.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","206.96","59.3","","198.65","198.65","198.65","470","30.54","273.79","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","349.00","261.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","206.96","59.3","","198.65","193.91","198.65","1 through 10","30.54","273.79","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","273.79","78.45","","260.62","154.45","260.62","403","30.54","273.79","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","16","13.9","114","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","120.00","90.00","TRICARE [160005]","HB NWH TRICARE","114.00","95","","17.09","17.09","17.09","1 through 10","13.9","114","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","117.00","1 through 10","14.61","94.14","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","41.08","89.95","1 through 10","14.61","94.14","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","85.62","1 through 10","13.45","147.25","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","14.14","121.6","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","88.28","57.7","","171.80","171.80","171.80","1 through 10","46.42","120.03","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","92.57","60.5","","471.60","471.60","471.60","1 through 10","46.42","120.03","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","464.71","67.87","1012.10","221","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","293.04","293.04","293.04","11","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","983.89","983.89","983.89","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","43.50","58","","677.18","677.18","677.18","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","46.88","62.5","","46.58","46.58","46.58","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","747.15","747.15","747.15","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","1141.67","481.21","1141.67","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","76.54","76.54","76.54","1 through 10","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","273.64","94.28","1367.51","138","33.34","58.43","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","720.78","230.14","2010.94","427","37.5","58.84","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","344.45","344.45","344.45","1 through 10","37.5","58.84","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","1120.13","1120.13","1120.13","1 through 10","37.5","58.84","percent of total billed charges",""
"WASHER 2.5/3MM 2.5 / SCREW DART FIRE COMPRESSION","SUP-ITM-10133788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","456.17","105.33","1284.66","242","37.5","58.84","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","AETNA [1001]","HB CH AETNA HMO / PPO","48.97","58.3","","464.71","67.87","1012.10","221","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.97","58.3","","293.04","293.04","293.04","11","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.52","53","","983.89","983.89","983.89","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","48.72","58","","677.18","677.18","677.18","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","52.50","62.5","","46.58","46.58","46.58","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","747.15","747.15","747.15","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.34","44.45","","1141.67","481.21","1141.67","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.34","44.45","","76.54","76.54","76.54","1 through 10","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB CH WELLPOINT","65.44","77.91","","273.64","94.28","1367.51","138","37.34","65.44","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.81","59.3","","720.78","230.14","2010.94","427","42","65.9","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","49.81","59.3","","344.45","344.45","344.45","1 through 10","42","65.9","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","1120.13","1120.13","1120.13","1 through 10","42","65.9","percent of total billed charges",""
"WASHER 3.5X4MM / SCREW DART FIRE COMPRESSION","SUP-ITM-10133770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","456.17","105.33","1284.66","242","42","65.9","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","464.71","67.87","1012.10","221","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","293.04","293.04","293.04","11","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","983.89","983.89","983.89","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","153.12","58","","677.18","677.18","677.18","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","165.00","62.5","","46.58","46.58","46.58","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","747.15","747.15","747.15","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","1141.67","481.21","1141.67","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","76.54","76.54","76.54","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","273.64","94.28","1367.51","138","117.35","205.68","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","720.78","230.14","2010.94","427","132","207.11","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","156.55","59.3","","344.45","344.45","344.45","1 through 10","132","207.11","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","1120.13","1120.13","1120.13","1 through 10","132","207.11","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","456.17","105.33","1284.66","242","132","207.11","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","AETNA [1001]","HB CH AETNA HMO / PPO","35.59","58.3","","464.71","67.87","1012.10","221","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","35.59","58.3","","293.04","293.04","293.04","11","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.36","53","","983.89","983.89","983.89","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","35.41","58","","677.18","677.18","677.18","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","38.16","62.5","","46.58","46.58","46.58","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","44.57","73","","747.15","747.15","747.15","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.14","44.45","","1141.67","481.21","1141.67","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.14","44.45","","76.54","76.54","76.54","1 through 10","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","WELLPOINT [1015]","HB CH WELLPOINT","47.56","77.91","","273.64","94.28","1367.51","138","27.14","47.56","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.20","59.3","","720.78","230.14","2010.94","427","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","36.20","59.3","","344.45","344.45","344.45","1 through 10","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.89","78.45","","1120.13","1120.13","1120.13","1 through 10","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.89","78.45","","456.17","105.33","1284.66","242","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","AETNA [1001]","HB CH AETNA HMO / PPO","38.18","58.3","","464.71","67.87","1012.10","221","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","38.18","58.3","","293.04","293.04","293.04","11","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.71","53","","983.89","983.89","983.89","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","37.98","58","","677.18","677.18","677.18","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","40.93","62.5","","46.58","46.58","46.58","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","47.81","73","","747.15","747.15","747.15","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.11","44.45","","1141.67","481.21","1141.67","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.11","44.45","","76.54","76.54","76.54","1 through 10","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","WELLPOINT [1015]","HB CH WELLPOINT","51.02","77.91","","273.64","94.28","1367.51","138","29.11","51.02","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.84","59.3","","720.78","230.14","2010.94","427","32.75","51.38","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","38.84","59.3","","344.45","344.45","344.45","1 through 10","32.75","51.38","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","51.38","78.45","","1120.13","1120.13","1120.13","1 through 10","32.75","51.38","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.38","78.45","","456.17","105.33","1284.66","242","32.75","51.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","AETNA [1001]","HB CH AETNA HMO / PPO","31.71","58.3","","464.71","67.87","1012.10","221","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.71","58.3","","293.04","293.04","293.04","11","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.83","53","","983.89","983.89","983.89","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","31.55","58","","677.18","677.18","677.18","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","33.99","62.5","","46.58","46.58","46.58","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.70","73","","747.15","747.15","747.15","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.18","44.45","","1141.67","481.21","1141.67","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.18","44.45","","76.54","76.54","76.54","1 through 10","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","WELLPOINT [1015]","HB CH WELLPOINT","42.38","77.91","","273.64","94.28","1367.51","138","24.18","42.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.25","59.3","","720.78","230.14","2010.94","427","27.2","42.67","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","32.25","59.3","","344.45","344.45","344.45","1 through 10","27.2","42.67","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","42.67","78.45","","1120.13","1120.13","1120.13","1 through 10","27.2","42.67","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.67","78.45","","456.17","105.33","1284.66","242","27.2","42.67","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","464.71","67.87","1012.10","221","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","293.04","293.04","293.04","11","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","983.89","983.89","983.89","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","60.90","58","","677.18","677.18","677.18","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","65.63","62.5","","46.58","46.58","46.58","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","747.15","747.15","747.15","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","1141.67","481.21","1141.67","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","76.54","76.54","76.54","1 through 10","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","273.64","94.28","1367.51","138","46.67","81.81","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","720.78","230.14","2010.94","427","52.5","82.37","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.27","59.3","","344.45","344.45","344.45","1 through 10","52.5","82.37","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","1120.13","1120.13","1120.13","1 through 10","52.5","82.37","percent of total billed charges",""
"WASHER CANNULATED 6.5MM SCREW QUICKFIX TITANIUM","SUP-ITM-10153984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","456.17","105.33","1284.66","242","52.5","82.37","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","AETNA [1001]","HB CH AETNA HMO / PPO","61.85","58.3","","464.71","67.87","1012.10","221","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.85","58.3","","293.04","293.04","293.04","11","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","56.23","53","","983.89","983.89","983.89","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","61.53","58","","677.18","677.18","677.18","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","66.31","62.5","","46.58","46.58","46.58","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","77.45","73","","747.15","747.15","747.15","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.16","44.45","","1141.67","481.21","1141.67","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.16","44.45","","76.54","76.54","76.54","1 through 10","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","WELLPOINT [1015]","HB CH WELLPOINT","82.65","77.91","","273.64","94.28","1367.51","138","47.16","82.65","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.91","59.3","","720.78","230.14","2010.94","427","53.05","83.23","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","62.91","59.3","","344.45","344.45","344.45","1 through 10","53.05","83.23","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","83.23","78.45","","1120.13","1120.13","1120.13","1 through 10","53.05","83.23","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.23","78.45","","456.17","105.33","1284.66","242","53.05","83.23","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","AETNA [1001]","HB CH AETNA HMO / PPO","45.47","58.3","","464.71","67.87","1012.10","221","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.47","58.3","","293.04","293.04","293.04","11","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.34","53","","983.89","983.89","983.89","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","45.24","58","","677.18","677.18","677.18","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","48.75","62.5","","46.58","46.58","46.58","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","747.15","747.15","747.15","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","1141.67","481.21","1141.67","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","76.54","76.54","76.54","1 through 10","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","WELLPOINT [1015]","HB CH WELLPOINT","60.77","77.91","","273.64","94.28","1367.51","138","34.67","60.77","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.25","59.3","","720.78","230.14","2010.94","427","39","61.19","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","46.25","59.3","","344.45","344.45","344.45","1 through 10","39","61.19","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","1120.13","1120.13","1120.13","1 through 10","39","61.19","percent of total billed charges",""
"WASHER FIXATION 7.5MM SCREW","SUP-ITM-10133294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","456.17","105.33","1284.66","242","39","61.19","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","AETNA [1001]","HB CH AETNA HMO / PPO","258.85","58.3","","464.71","67.87","1012.10","221","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","258.85","58.3","","293.04","293.04","293.04","11","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","235.32","53","","983.89","983.89","983.89","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","257.52","58","","677.18","677.18","677.18","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","277.50","62.5","","46.58","46.58","46.58","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","324.12","73","","747.15","747.15","747.15","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.36","44.45","","1141.67","481.21","1141.67","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.36","44.45","","76.54","76.54","76.54","1 through 10","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","WELLPOINT [1015]","HB CH WELLPOINT","345.92","77.91","","273.64","94.28","1367.51","138","197.36","345.92","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","263.29","59.3","","720.78","230.14","2010.94","427","222","348.32","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","263.29","59.3","","344.45","344.45","344.45","1 through 10","222","348.32","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","348.32","78.45","","1120.13","1120.13","1120.13","1 through 10","222","348.32","percent of total billed charges",""
"WASHER FOOT 5.5MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","348.32","78.45","","456.17","105.33","1284.66","242","222","348.32","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","AETNA [1001]","HB CH AETNA HMO / PPO","59.12","58.3","","464.71","67.87","1012.10","221","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","59.12","58.3","","293.04","293.04","293.04","11","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","53.74","53","","983.89","983.89","983.89","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","58.81","58","","677.18","677.18","677.18","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","63.38","62.5","","46.58","46.58","46.58","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","74.02","73","","747.15","747.15","747.15","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.07","44.45","","1141.67","481.21","1141.67","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.07","44.45","","76.54","76.54","76.54","1 through 10","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.40","76.05","WELLPOINT [1015]","HB CH WELLPOINT","79.00","77.91","","273.64","94.28","1367.51","138","45.07","79","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.40","76.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.13","59.3","","720.78","230.14","2010.94","427","50.7","79.55","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.40","76.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","60.13","59.3","","344.45","344.45","344.45","1 through 10","50.7","79.55","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.40","76.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","79.55","78.45","","1120.13","1120.13","1120.13","1 through 10","50.7","79.55","percent of total billed charges",""
"WASHER FOR 3.5 CANNULATED SCREW","SUP-ITM-10327783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.40","76.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.55","78.45","","456.17","105.33","1284.66","242","50.7","79.55","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","464.71","67.87","1012.10","221","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","293.04","293.04","293.04","11","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","983.89","983.89","983.89","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","153.12","58","","677.18","677.18","677.18","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","165.00","62.5","","46.58","46.58","46.58","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","747.15","747.15","747.15","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","1141.67","481.21","1141.67","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","76.54","76.54","76.54","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","273.64","94.28","1367.51","138","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","720.78","230.14","2010.94","427","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","156.55","59.3","","344.45","344.45","344.45","1 through 10","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","1120.13","1120.13","1120.13","1 through 10","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.0MM","SUP-ITM-10243339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","456.17","105.33","1284.66","242","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","464.71","67.87","1012.10","221","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","293.04","293.04","293.04","11","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","983.89","983.89","983.89","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","153.12","58","","677.18","677.18","677.18","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","165.00","62.5","","46.58","46.58","46.58","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","747.15","747.15","747.15","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","1141.67","481.21","1141.67","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","76.54","76.54","76.54","1 through 10","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","273.64","94.28","1367.51","138","117.35","205.68","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","720.78","230.14","2010.94","427","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","156.55","59.3","","344.45","344.45","344.45","1 through 10","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","1120.13","1120.13","1120.13","1 through 10","132","207.11","percent of total billed charges",""
"WASHER HEADED 3.5MM","SUP-ITM-10243338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","456.17","105.33","1284.66","242","132","207.11","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","464.71","67.87","1012.10","221","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","293.04","293.04","293.04","11","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","983.89","983.89","983.89","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","478.50","58","","677.18","677.18","677.18","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","515.63","62.5","","46.58","46.58","46.58","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","747.15","747.15","747.15","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","1141.67","481.21","1141.67","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","76.54","76.54","76.54","1 through 10","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","273.64","94.28","1367.51","138","366.71","642.76","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","720.78","230.14","2010.94","427","412.5","647.21","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","489.23","59.3","","344.45","344.45","344.45","1 through 10","412.5","647.21","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","1120.13","1120.13","1120.13","1 through 10","412.5","647.21","percent of total billed charges",""
"WASHER OLECRANON SLED","SUP-ITM-10082051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","456.17","105.33","1284.66","242","412.5","647.21","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","464.71","67.87","1012.10","221","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","293.04","293.04","293.04","11","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","983.89","983.89","983.89","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","174.00","58","","677.18","677.18","677.18","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","187.50","62.5","","46.58","46.58","46.58","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","747.15","747.15","747.15","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","1141.67","481.21","1141.67","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","76.54","76.54","76.54","1 through 10","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","273.64","94.28","1367.51","138","133.35","233.73","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","720.78","230.14","2010.94","427","150","235.35","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","177.90","59.3","","344.45","344.45","344.45","1 through 10","150","235.35","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1120.13","1120.13","1120.13","1 through 10","150","235.35","percent of total billed charges",""
"WASHER ORTHOPEDIC 18MM SPIKED SIZE CANCELLOUS SCREW","SUP-ITM-10027310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","456.17","105.33","1284.66","242","150","235.35","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","AETNA [1001]","HB CH AETNA HMO / PPO","106.72","58.3","","464.71","67.87","1012.10","221","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.72","58.3","","293.04","293.04","293.04","11","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.02","53","","983.89","983.89","983.89","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","106.17","58","","677.18","677.18","677.18","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","114.41","62.5","","46.58","46.58","46.58","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","747.15","747.15","747.15","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","1141.67","481.21","1141.67","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","76.54","76.54","76.54","1 through 10","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","WELLPOINT [1015]","HB CH WELLPOINT","142.62","77.91","","273.64","94.28","1367.51","138","81.37","142.62","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.55","59.3","","720.78","230.14","2010.94","427","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","108.55","59.3","","344.45","344.45","344.45","1 through 10","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","1120.13","1120.13","1120.13","1 through 10","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","456.17","105.33","1284.66","242","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","AETNA [1001]","HB CH AETNA HMO / PPO","159.44","58.3","","464.71","67.87","1012.10","221","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","159.44","58.3","","293.04","293.04","293.04","11","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","144.94","53","","983.89","983.89","983.89","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","158.62","58","","677.18","677.18","677.18","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","170.93","62.5","","46.58","46.58","46.58","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","199.64","73","","747.15","747.15","747.15","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.56","44.45","","1141.67","481.21","1141.67","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.56","44.45","","76.54","76.54","76.54","1 through 10","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","both","","","273.48","205.11","WELLPOINT [1015]","HB CH WELLPOINT","213.07","77.91","","273.64","94.28","1367.51","138","121.56","213.07","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.48","205.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","162.17","59.3","","720.78","230.14","2010.94","427","136.74","214.55","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.48","205.11","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","162.17","59.3","","344.45","344.45","344.45","1 through 10","136.74","214.55","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.48","205.11","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","214.55","78.45","","1120.13","1120.13","1120.13","1 through 10","136.74","214.55","percent of total billed charges",""
"WASHER ORTHOPEDIC 3MM TITANIUM","SUP-ITM-10080875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","273.48","205.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","214.55","78.45","","456.17","105.33","1284.66","242","136.74","214.55","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","464.71","67.87","1012.10","221","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","293.04","293.04","293.04","11","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","983.89","983.89","983.89","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","139.20","58","","677.18","677.18","677.18","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","150.00","62.5","","46.58","46.58","46.58","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","747.15","747.15","747.15","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","1141.67","481.21","1141.67","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","76.54","76.54","76.54","1 through 10","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","273.64","94.28","1367.51","138","106.68","186.98","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","720.78","230.14","2010.94","427","120","188.28","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","142.32","59.3","","344.45","344.45","344.45","1 through 10","120","188.28","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","1120.13","1120.13","1120.13","1 through 10","120","188.28","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","456.17","105.33","1284.66","242","120","188.28","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","AETNA [1001]","HB CH AETNA HMO / PPO","144.61","58.3","","464.71","67.87","1012.10","221","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.61","58.3","","293.04","293.04","293.04","11","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.46","53","","983.89","983.89","983.89","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","143.86","58","","677.18","677.18","677.18","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","155.03","62.5","","46.58","46.58","46.58","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","181.07","73","","747.15","747.15","747.15","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.25","44.45","","1141.67","481.21","1141.67","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.25","44.45","","76.54","76.54","76.54","1 through 10","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.04","186.03","WELLPOINT [1015]","HB CH WELLPOINT","193.25","77.91","","273.64","94.28","1367.51","138","110.25","193.25","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.04","186.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","147.09","59.3","","720.78","230.14","2010.94","427","124.02","194.59","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.04","186.03","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","147.09","59.3","","344.45","344.45","344.45","1 through 10","124.02","194.59","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.04","186.03","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","194.59","78.45","","1120.13","1120.13","1120.13","1 through 10","124.02","194.59","percent of total billed charges",""
"WASHER SCREW 2.0MM BONE ASNIS MICRO SS","SUP-ITM-10118024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.04","186.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.59","78.45","","456.17","105.33","1284.66","242","124.02","194.59","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","AETNA [1001]","HB CH AETNA HMO / PPO","91.25","58.3","","464.71","67.87","1012.10","221","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.25","58.3","","293.04","293.04","293.04","11","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.95","53","","983.89","983.89","983.89","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","90.78","58","","677.18","677.18","677.18","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","97.82","62.5","","46.58","46.58","46.58","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.25","73","","747.15","747.15","747.15","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.57","44.45","","1141.67","481.21","1141.67","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.57","44.45","","76.54","76.54","76.54","1 through 10","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","WELLPOINT [1015]","HB CH WELLPOINT","121.94","77.91","","273.64","94.28","1367.51","138","69.57","121.94","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.81","59.3","","720.78","230.14","2010.94","427","78.26","122.78","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","92.81","59.3","","344.45","344.45","344.45","1 through 10","78.26","122.78","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","122.78","78.45","","1120.13","1120.13","1120.13","1 through 10","78.26","122.78","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.78","78.45","","456.17","105.33","1284.66","242","78.26","122.78","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","AETNA [1001]","HB CH AETNA HMO / PPO","119.84","58.3","","464.71","67.87","1012.10","221","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","119.84","58.3","","293.04","293.04","293.04","11","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","108.95","53","","983.89","983.89","983.89","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","119.22","58","","677.18","677.18","677.18","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","128.48","62.5","","46.58","46.58","46.58","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","150.06","73","","747.15","747.15","747.15","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.37","44.45","","1141.67","481.21","1141.67","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.37","44.45","","76.54","76.54","76.54","1 through 10","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.56","154.17","WELLPOINT [1015]","HB CH WELLPOINT","160.15","77.91","","273.64","94.28","1367.51","138","91.37","160.15","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.56","154.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.90","59.3","","720.78","230.14","2010.94","427","102.78","161.26","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.56","154.17","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","121.90","59.3","","344.45","344.45","344.45","1 through 10","102.78","161.26","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.56","154.17","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","161.26","78.45","","1120.13","1120.13","1120.13","1 through 10","102.78","161.26","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.56","154.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","161.26","78.45","","456.17","105.33","1284.66","242","102.78","161.26","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","AETNA [1001]","HB CH AETNA HMO / PPO","30.22","58.3","","464.71","67.87","1012.10","221","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","30.22","58.3","","293.04","293.04","293.04","11","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","27.48","53","","983.89","983.89","983.89","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","30.07","58","","677.18","677.18","677.18","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","32.40","62.5","","46.58","46.58","46.58","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","37.84","73","","747.15","747.15","747.15","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.04","44.45","","1141.67","481.21","1141.67","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.04","44.45","","76.54","76.54","76.54","1 through 10","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","WELLPOINT [1015]","HB CH WELLPOINT","40.39","77.91","","273.64","94.28","1367.51","138","23.04","40.39","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.74","59.3","","720.78","230.14","2010.94","427","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","30.74","59.3","","344.45","344.45","344.45","1 through 10","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","40.67","78.45","","1120.13","1120.13","1120.13","1 through 10","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.67","78.45","","456.17","105.33","1284.66","242","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","AETNA [1001]","HB CH AETNA HMO / PPO","171.40","58.3","","464.71","67.87","1012.10","221","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","171.40","58.3","","293.04","293.04","293.04","11","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","155.82","53","","983.89","983.89","983.89","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","170.52","58","","677.18","677.18","677.18","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","183.75","62.5","","46.58","46.58","46.58","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","214.62","73","","747.15","747.15","747.15","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","1141.67","481.21","1141.67","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","76.54","76.54","76.54","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB CH WELLPOINT","229.06","77.91","","273.64","94.28","1367.51","138","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","174.34","59.3","","720.78","230.14","2010.94","427","147","230.64","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","174.34","59.3","","344.45","344.45","344.45","1 through 10","147","230.64","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","1120.13","1120.13","1120.13","1 through 10","147","230.64","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","456.17","105.33","1284.66","242","147","230.64","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","AETNA [1001]","HB CH AETNA HMO / PPO","241.36","58.3","","464.71","67.87","1012.10","221","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","241.36","58.3","","293.04","293.04","293.04","11","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","219.42","53","","983.89","983.89","983.89","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","240.12","58","","677.18","677.18","677.18","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","258.75","62.5","","46.58","46.58","46.58","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","302.22","73","","747.15","747.15","747.15","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.02","44.45","","1141.67","481.21","1141.67","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.02","44.45","","76.54","76.54","76.54","1 through 10","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.00","310.50","WELLPOINT [1015]","HB CH WELLPOINT","322.55","77.91","","273.64","94.28","1367.51","138","184.02","322.55","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.00","310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","245.50","59.3","","720.78","230.14","2010.94","427","207","324.78","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.00","310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","245.50","59.3","","344.45","344.45","344.45","1 through 10","207","324.78","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.00","310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","324.78","78.45","","1120.13","1120.13","1120.13","1 through 10","207","324.78","percent of total billed charges",""
"WASHER SCREW 6.5MM","SUP-ITM-10297927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.78","78.45","","456.17","105.33","1284.66","242","207","324.78","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","AETNA [1001]","HB CH AETNA HMO / PPO","56.14","58.3","","464.71","67.87","1012.10","221","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","56.14","58.3","","293.04","293.04","293.04","11","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.04","53","","983.89","983.89","983.89","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","55.85","58","","677.18","677.18","677.18","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","60.19","62.5","","46.58","46.58","46.58","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","70.30","73","","747.15","747.15","747.15","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.81","44.45","","1141.67","481.21","1141.67","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.81","44.45","","76.54","76.54","76.54","1 through 10","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","WELLPOINT [1015]","HB CH WELLPOINT","75.03","77.91","","273.64","94.28","1367.51","138","42.81","75.03","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","57.11","59.3","","720.78","230.14","2010.94","427","48.15","75.55","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","57.11","59.3","","344.45","344.45","344.45","1 through 10","48.15","75.55","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","75.55","78.45","","1120.13","1120.13","1120.13","1 through 10","48.15","75.55","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.55","78.45","","456.17","105.33","1284.66","242","48.15","75.55","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","AETNA [1001]","HB CH AETNA HMO / PPO","171.40","58.3","","464.71","67.87","1012.10","221","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","171.40","58.3","","293.04","293.04","293.04","11","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","155.82","53","","983.89","983.89","983.89","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","170.52","58","","677.18","677.18","677.18","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","183.75","62.5","","46.58","46.58","46.58","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","214.62","73","","747.15","747.15","747.15","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","1141.67","481.21","1141.67","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.68","44.45","","76.54","76.54","76.54","1 through 10","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB CH WELLPOINT","229.06","77.91","","273.64","94.28","1367.51","138","130.68","229.06","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","174.34","59.3","","720.78","230.14","2010.94","427","147","230.64","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","174.34","59.3","","344.45","344.45","344.45","1 through 10","147","230.64","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","1120.13","1120.13","1120.13","1 through 10","147","230.64","percent of total billed charges",""
"WASHER SCREW 7MM FLAT BLUE","SUP-ITM-10082983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","230.64","78.45","","456.17","105.33","1284.66","242","147","230.64","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB CH AETNA HMO / PPO","398.77","58.3","","464.71","67.87","1012.10","221","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","398.77","58.3","","293.04","293.04","293.04","11","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.52","53","","983.89","983.89","983.89","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","396.72","58","","677.18","677.18","677.18","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","427.50","62.5","","46.58","46.58","46.58","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.32","73","","747.15","747.15","747.15","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.04","44.45","","1141.67","481.21","1141.67","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.04","44.45","","76.54","76.54","76.54","1 through 10","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","WELLPOINT [1015]","HB CH WELLPOINT","532.90","77.91","","273.64","94.28","1367.51","138","304.04","532.9","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","405.61","59.3","","720.78","230.14","2010.94","427","342","536.6","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","405.61","59.3","","344.45","344.45","344.45","1 through 10","342","536.6","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","1120.13","1120.13","1120.13","1 through 10","342","536.6","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","456.17","105.33","1284.66","242","342","536.6","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","AETNA [1001]","HB CH AETNA HMO / PPO","209.32","58.3","","464.71","67.87","1012.10","221","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.32","58.3","","293.04","293.04","293.04","11","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.29","53","","983.89","983.89","983.89","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","208.24","58","","677.18","677.18","677.18","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","224.40","62.5","","46.58","46.58","46.58","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","747.15","747.15","747.15","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","1141.67","481.21","1141.67","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","76.54","76.54","76.54","1 through 10","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","WELLPOINT [1015]","HB CH WELLPOINT","279.73","77.91","","273.64","94.28","1367.51","138","159.59","279.73","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.91","59.3","","720.78","230.14","2010.94","427","179.52","281.67","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","212.91","59.3","","344.45","344.45","344.45","1 through 10","179.52","281.67","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","1120.13","1120.13","1120.13","1 through 10","179.52","281.67","percent of total billed charges",""
"WASHER SPHERICAL 6.5X7.3MM LG ROUND FOR CANNULATED SCREW","SUP-ITM-10037541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","456.17","105.33","1284.66","242","179.52","281.67","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","464.71","67.87","1012.10","221","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","89.20","58.3","","293.04","293.04","293.04","11","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.09","53","","983.89","983.89","983.89","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","88.74","58","","677.18","677.18","677.18","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","95.63","62.5","","46.58","46.58","46.58","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","747.15","747.15","747.15","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","1141.67","481.21","1141.67","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","76.54","76.54","76.54","1 through 10","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","WELLPOINT [1015]","HB CH WELLPOINT","119.20","77.91","","273.64","94.28","1367.51","138","68.01","119.2","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","720.78","230.14","2010.94","427","76.5","120.03","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","90.73","59.3","","344.45","344.45","344.45","1 through 10","76.5","120.03","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","1120.13","1120.13","1120.13","1 through 10","76.5","120.03","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","456.17","105.33","1284.66","242","76.5","120.03","percent of total billed charges",""
"West Nile Virus Antibody","PX-30001008","CDM","86789","CPT","0302","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","97.82","97.82","97.82","1 through 10","14.84","106.69","percent of total billed charges",""
"West Nile Virus Antibody Igm","PX-30001007","CDM","86788","CPT","0302","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","128.66","78.45","","118.29","118.29","118.29","1 through 10","14.72","128.66","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","47.97","35.98","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","27.68","57.7","","28.93","28.93","28.93","1 through 10","21.32","957.19","percent of total billed charges",""
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","both","","","3744.00","2808.00","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","2733.12","other","OPPS APC"
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","both","","","3744.00","2808.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","313.68","104.56","313.68","1 through 10","99.34","2733.12","other","OPPS APC"
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","both","","","3744.00","2808.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.67","102.47","102.67","1 through 10","99.34","2733.12","other","OPPS APC"
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","outpatient","","","3744.00","2808.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1837.18","49.07","","3641.00","3641.00","3641.00","1 through 10","142.04","1875.74","percent of total billed charges",""
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","outpatient","","","3744.00","2808.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1875.74","50.1","","188.55","188.55","188.55","1 through 10","142.04","1875.74","percent of total billed charges",""
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","outpatient","","","3744.00","2808.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1330.62","35.54","","1268.16","1268.16","1268.16","1 through 10","142.04","1875.74","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","52.78","35.48","309.60","1 through 10","120.02","210.36","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","173.31","173.31","173.31","1 through 10","120.02","210.36","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","168.75","62.5","","26.48","26.48","26.48","1 through 10","120.02","210.36","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","127.34","127.34","127.34","1 through 10","120.02","210.36","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","99.24","60.15","134.68","19","120.02","210.36","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","59.44","59.44","59.44","1 through 10","135","211.82","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","239.87","239.87","239.87","1 through 10","135","211.82","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","77.27","46.21","95.91","26","135","211.82","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","AETNA [1001]","HB CH AETNA HMO / PPO","33.03","58.3","","464.71","67.87","1012.10","221","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","33.03","58.3","","293.04","293.04","293.04","11","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.02","53","","983.89","983.89","983.89","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","32.86","58","","677.18","677.18","677.18","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","35.41","62.5","","46.58","46.58","46.58","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","41.35","73","","747.15","747.15","747.15","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.18","44.45","","1141.67","481.21","1141.67","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.18","44.45","","76.54","76.54","76.54","1 through 10","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","both","","","56.65","42.49","WELLPOINT [1015]","HB CH WELLPOINT","44.14","77.91","","273.64","94.28","1367.51","138","25.18","44.14","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","56.65","42.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","33.59","59.3","","720.78","230.14","2010.94","427","28.33","44.44","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","56.65","42.49","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","33.59","59.3","","344.45","344.45","344.45","1 through 10","28.33","44.44","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","56.65","42.49","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","44.44","78.45","","1120.13","1120.13","1120.13","1 through 10","28.33","44.44","percent of total billed charges",""
"WIRE BONE 229MM 0.045IN KIRSCHNER SS SMOOTH DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","56.65","42.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","44.44","78.45","","456.17","105.33","1284.66","242","28.33","44.44","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","464.71","67.87","1012.10","221","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","293.04","293.04","293.04","11","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","983.89","983.89","983.89","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","153.12","58","","677.18","677.18","677.18","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","165.00","62.5","","46.58","46.58","46.58","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","747.15","747.15","747.15","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","1141.67","481.21","1141.67","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","76.54","76.54","76.54","1 through 10","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","273.64","94.28","1367.51","138","117.35","205.68","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","720.78","230.14","2010.94","427","132","207.11","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","156.55","59.3","","344.45","344.45","344.45","1 through 10","132","207.11","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","1120.13","1120.13","1120.13","1 through 10","132","207.11","percent of total billed charges",""
"WIRE FLUOROBAND 2.3X230MM SINGLE TROCAR TIP THREADED","SUP-ITM-10241225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","456.17","105.33","1284.66","242","132","207.11","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","AETNA [1001]","HB CH AETNA HMO / PPO","113.06","58.3","","464.71","67.87","1012.10","221","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","113.06","58.3","","293.04","293.04","293.04","11","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","102.78","53","","983.89","983.89","983.89","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","112.47","58","","677.18","677.18","677.18","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","121.20","62.5","","46.58","46.58","46.58","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","141.56","73","","747.15","747.15","747.15","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.20","44.45","","1141.67","481.21","1141.67","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.20","44.45","","76.54","76.54","76.54","1 through 10","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","WELLPOINT [1015]","HB CH WELLPOINT","151.08","77.91","","273.64","94.28","1367.51","138","86.2","151.08","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","114.99","59.3","","720.78","230.14","2010.94","427","96.96","152.13","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","114.99","59.3","","344.45","344.45","344.45","1 through 10","96.96","152.13","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","152.13","78.45","","1120.13","1120.13","1120.13","1 through 10","96.96","152.13","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.13","78.45","","456.17","105.33","1284.66","242","96.96","152.13","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","464.71","67.87","1012.10","221","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.53","58.3","","293.04","293.04","293.04","11","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","983.89","983.89","983.89","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","162.69","58","","677.18","677.18","677.18","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","175.31","62.5","","46.58","46.58","46.58","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","747.15","747.15","747.15","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","1141.67","481.21","1141.67","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","76.54","76.54","76.54","1 through 10","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","273.64","94.28","1367.51","138","124.68","218.54","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.34","59.3","","720.78","230.14","2010.94","427","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","166.34","59.3","","344.45","344.45","344.45","1 through 10","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","1120.13","1120.13","1120.13","1 through 10","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","456.17","105.33","1284.66","242","140.25","220.05","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","AETNA [1001]","HB CH AETNA HMO / PPO","769.56","58.3","","464.71","67.87","1012.10","221","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","769.56","58.3","","293.04","293.04","293.04","11","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","699.60","53","","983.89","983.89","983.89","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","765.60","58","","677.18","677.18","677.18","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","825.00","62.5","","46.58","46.58","46.58","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","963.60","73","","747.15","747.15","747.15","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.74","44.45","","1141.67","481.21","1141.67","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.74","44.45","","76.54","76.54","76.54","1 through 10","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","WELLPOINT [1015]","HB CH WELLPOINT","1028.41","77.91","","273.64","94.28","1367.51","138","586.74","1028.41","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","782.76","59.3","","720.78","230.14","2010.94","427","660","1035.54","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","782.76","59.3","","344.45","344.45","344.45","1 through 10","660","1035.54","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","1120.13","1120.13","1120.13","1 through 10","660","1035.54","percent of total billed charges",""
"WIRE STEEL 50MM 5 HOLE PLATE BONE STAINLESS FORM FIXATION","SUP-ITM-10092106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","456.17","105.33","1284.66","242","660","1035.54","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","464.71","67.87","1012.10","221","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","293.04","293.04","293.04","11","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","983.89","983.89","983.89","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","739.50","58","","677.18","677.18","677.18","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","796.88","62.5","","46.58","46.58","46.58","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","747.15","747.15","747.15","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","1141.67","481.21","1141.67","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","76.54","76.54","76.54","1 through 10","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","273.64","94.28","1367.51","138","566.74","993.35","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","720.78","230.14","2010.94","427","637.5","1000.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","756.08","59.3","","344.45","344.45","344.45","1 through 10","637.5","1000.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","1120.13","1120.13","1120.13","1 through 10","637.5","1000.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","456.17","105.33","1284.66","242","637.5","1000.24","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","AETNA [1001]","HB CH AETNA HMO / PPO","47.22","58.3","","464.71","67.87","1012.10","221","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.22","58.3","","293.04","293.04","293.04","11","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.93","53","","983.89","983.89","983.89","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","46.98","58","","677.18","677.18","677.18","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","50.63","62.5","","46.58","46.58","46.58","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.13","73","","747.15","747.15","747.15","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","1141.67","481.21","1141.67","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","76.54","76.54","76.54","1 through 10","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.00","60.75","WELLPOINT [1015]","HB CH WELLPOINT","63.11","77.91","","273.64","94.28","1367.51","138","36","63.11","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","720.78","230.14","2010.94","427","40.5","63.54","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","48.03","59.3","","344.45","344.45","344.45","1 through 10","40.5","63.54","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","1120.13","1120.13","1120.13","1 through 10","40.5","63.54","percent of total billed charges",""
"WIRE TROCAR 1.1X100MM TIP APTUS KIRSCHNER S/S IMPLANTABLE","SUP-ITM-10114321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","456.17","105.33","1284.66","242","40.5","63.54","percent of total billed charges",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","64887.66","48665.74","MEDICARE [2001]","HB NWH MEDICARE","26985.52","","Case rate ($26,985.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $27,721.46, add-ons for qualifying new technology services are included. If operating cost exceeds $72,863.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $5,004.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $24,923.32. The transfer operating threshold is the transfer adjustment factor * $27,721.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,062.21. The transfer capital threshold is the transfer adjustment factor * $2,062.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28141.95","28141.58","28192.54","1 through 10","26445.81","31972.4","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","85429.47","64072.10","AETNA [1001]","HB NWH AETNA MEDICARE REPLACEMENT","50861.44","","Case rate ($49,380.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $50,726.72, add-ons for qualifying new technology services are included. If operating cost exceeds $95,868.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,715.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $45,606.47. The transfer operating threshold is the transfer adjustment factor * $50,726.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,773.57. The transfer capital threshold is the transfer adjustment factor * $3,773.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","48341.19","48341.19","48341.19","1 through 10","48392.44","54294.59","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","85429.47","64072.10","MEDICARE [2001]","HB NWH MEDICARE","54294.59","","Case rate ($54,294.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $50,726.72, add-ons for qualifying new technology services are included. If operating cost exceeds $95,868.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $6,715.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $50,521.02. The transfer operating threshold is the transfer adjustment factor * $50,726.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,773.57. The transfer capital threshold is the transfer adjustment factor * $3,773.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","51640.74","51640.74","51640.74","1 through 10","48392.44","54294.59","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","29634.35","22225.76","MEDICARE [2001]","HB NWH MEDICARE","17372.93","","Case rate ($17,372.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $16,231.30, add-ons for qualifying new technology services are included. If operating cost exceeds $61,373.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,149.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $16,165.49. The transfer operating threshold is the transfer adjustment factor * $16,231.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,207.45. The transfer capital threshold is the transfer adjustment factor * $1,207.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16599.43","16599.43","16599.43","1 through 10","15484.39","17372.93","other","Inpatient DRG"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","","","","inpatient","","","35202.65","26401.99","MEDICARE [2001]","HB NWH MEDICARE","16587.09","","Case rate ($16,587.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.368, exceeds $17,039.44, add-ons for qualifying new technology services are included. If operating cost exceeds $62,181.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.024, exceeds $4,209.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $15,319.52. The transfer operating threshold is the transfer adjustment factor * $17,039.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.57. The transfer capital threshold is the transfer adjustment factor * $1,267.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18111.02","18111.02","18111.02","1 through 10","16255.35","18765.3664","other","Inpatient Replacement Plans DRG"
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","AETNA [1001]","HB CH AETNA HMO / PPO","2213.18","58.3","","464.71","67.87","1012.10","221","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2213.18","58.3","","293.04","293.04","293.04","11","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2011.99","53","","983.89","983.89","983.89","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2201.80","58","","677.18","677.18","677.18","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2372.63","62.5","","46.58","46.58","46.58","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2771.23","73","","747.15","747.15","747.15","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.41","44.45","","1141.67","481.21","1141.67","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.41","44.45","","76.54","76.54","76.54","1 through 10","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","WELLPOINT [1015]","HB CH WELLPOINT","2957.62","77.91","","273.64","94.28","1367.51","138","1687.41","2957.62","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","2251.15","59.3","","720.78","230.14","2010.94","427","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2251.15","59.3","","344.45","344.45","344.45","1 through 10","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2978.12","78.45","","1120.13","1120.13","1120.13","1 through 10","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2978.12","78.45","","456.17","105.33","1284.66","242","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","AETNA [1001]","HB CH AETNA HMO / PPO","2018.35","58.3","","464.71","67.87","1012.10","221","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2018.35","58.3","","293.04","293.04","293.04","11","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1834.86","53","","983.89","983.89","983.89","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2007.96","58","","677.18","677.18","677.18","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2163.75","62.5","","46.58","46.58","46.58","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2527.26","73","","747.15","747.15","747.15","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.86","44.45","","1141.67","481.21","1141.67","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.86","44.45","","76.54","76.54","76.54","1 through 10","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","both","","","3462.00","2596.50","WELLPOINT [1015]","HB CH WELLPOINT","2697.24","77.91","","273.64","94.28","1367.51","138","1538.86","2697.24","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2052.97","59.3","","720.78","230.14","2010.94","427","1731","2715.94","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2052.97","59.3","","344.45","344.45","344.45","1 through 10","1731","2715.94","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2715.94","78.45","","1120.13","1120.13","1120.13","1 through 10","1731","2715.94","percent of total billed charges",""
"WRIST PLATE 188MM SPANNING ACU LOC LONG","SUP-ITM-10189528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3462.00","2596.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2715.94","78.45","","456.17","105.33","1284.66","242","1731","2715.94","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","AETNA [1001]","HB CH AETNA HMO / PPO","5536.17","58.3","","464.71","67.87","1012.10","221","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5536.17","58.3","","293.04","293.04","293.04","11","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5032.88","53","","983.89","983.89","983.89","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","5507.68","58","","677.18","677.18","677.18","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","5935.00","62.5","","46.58","46.58","46.58","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6932.08","73","","747.15","747.15","747.15","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4220.97","44.45","","1141.67","481.21","1141.67","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4220.97","44.45","","76.54","76.54","76.54","1 through 10","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","9496.00","7122.00","WELLPOINT [1015]","HB CH WELLPOINT","7398.33","77.91","","273.64","94.28","1367.51","138","4220.97","7398.33","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9496.00","7122.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5631.13","59.3","","720.78","230.14","2010.94","427","4748","7449.61","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9496.00","7122.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","5631.13","59.3","","344.45","344.45","344.45","1 through 10","4748","7449.61","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9496.00","7122.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","7449.61","78.45","","1120.13","1120.13","1120.13","1 through 10","4748","7449.61","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9496.00","7122.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7449.61","78.45","","456.17","105.33","1284.66","242","4748","7449.61","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","AETNA [1001]","HB CH AETNA HMO / PPO","2002.61","58.3","","464.71","67.87","1012.10","221","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2002.61","58.3","","293.04","293.04","293.04","11","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1820.55","53","","983.89","983.89","983.89","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1992.30","58","","677.18","677.18","677.18","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2146.88","62.5","","46.58","46.58","46.58","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2507.55","73","","747.15","747.15","747.15","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1526.86","44.45","","1141.67","481.21","1141.67","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1526.86","44.45","","76.54","76.54","76.54","1 through 10","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.00","2576.25","WELLPOINT [1015]","HB CH WELLPOINT","2676.21","77.91","","273.64","94.28","1367.51","138","1526.86","2676.21","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.00","2576.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2036.96","59.3","","720.78","230.14","2010.94","427","1717.5","2694.76","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.00","2576.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2036.96","59.3","","344.45","344.45","344.45","1 through 10","1717.5","2694.76","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.00","2576.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2694.76","78.45","","1120.13","1120.13","1120.13","1 through 10","1717.5","2694.76","percent of total billed charges",""
"WRIST PLATE 3 HOLE 7 PEG N VOLAR ANGLE FIXED LT","SUP-ITM-10298436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.00","2576.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2694.76","78.45","","456.17","105.33","1284.66","242","1717.5","2694.76","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","AETNA [1001]","HB CH AETNA HMO / PPO","1084.38","58.3","","464.71","67.87","1012.10","221","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1084.38","58.3","","293.04","293.04","293.04","11","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","985.80","53","","983.89","983.89","983.89","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1078.80","58","","677.18","677.18","677.18","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1162.50","62.5","","46.58","46.58","46.58","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1357.80","73","","747.15","747.15","747.15","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","826.77","44.45","","1141.67","481.21","1141.67","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","826.77","44.45","","76.54","76.54","76.54","1 through 10","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","both","","","1860.00","1395.00","WELLPOINT [1015]","HB CH WELLPOINT","1449.13","77.91","","273.64","94.28","1367.51","138","826.77","1449.13","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1860.00","1395.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1102.98","59.3","","720.78","230.14","2010.94","427","930","1459.17","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1860.00","1395.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1102.98","59.3","","344.45","344.45","344.45","1 through 10","930","1459.17","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1860.00","1395.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1459.17","78.45","","1120.13","1120.13","1120.13","1 through 10","930","1459.17","percent of total billed charges",""
"WRIST PLATE 3 HOLE RADIAL TRIMED FIXATION SYSTEM COLUMN","SUP-ITM-10077043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1860.00","1395.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1459.17","78.45","","456.17","105.33","1284.66","242","930","1459.17","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","AETNA [1001]","HB CH AETNA HMO / PPO","1888.92","58.3","","464.71","67.87","1012.10","221","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1888.92","58.3","","293.04","293.04","293.04","11","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1717.20","53","","983.89","983.89","983.89","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1879.20","58","","677.18","677.18","677.18","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2025.00","62.5","","46.58","46.58","46.58","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2365.20","73","","747.15","747.15","747.15","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1440.18","44.45","","1141.67","481.21","1141.67","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1440.18","44.45","","76.54","76.54","76.54","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","WELLPOINT [1015]","HB CH WELLPOINT","2524.28","77.91","","273.64","94.28","1367.51","138","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1921.32","59.3","","720.78","230.14","2010.94","427","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1921.32","59.3","","344.45","344.45","344.45","1 through 10","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2541.78","78.45","","1120.13","1120.13","1120.13","1 through 10","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR LT 7 PEG","SUP-ITM-10094064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2541.78","78.45","","456.17","105.33","1284.66","242","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","AETNA [1001]","HB CH AETNA HMO / PPO","1888.92","58.3","","1530.90","1160.93","1884.08","89","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1717.20","53","","5253.92","5253.92","5253.92","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1879.20","58","","12181.47","12181.47","12181.47","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2025.00","62.5","","1350.68","1350.68","1350.68","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1440.18","44.45","","1910.74","891.94","1910.74","1 through 10","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3240.00","2430.00","WELLPOINT [1015]","HB CH WELLPOINT","2524.28","77.91","","1829.79","1561.50","2617.12","88","1440.18","2524.28","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1921.32","59.3","","1359.46","1201.30","1689.00","61","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1921.32","59.3","","1718.92","1718.92","1718.92","1 through 10","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE SS BEARING VOLAR RT 7 PEG","SUP-ITM-10126303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3240.00","2430.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2541.78","78.45","","1910.74","1019.06","2344.84","74","1620","2541.78","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","AETNA [1001]","HB CH AETNA HMO / PPO","1189.32","58.3","","464.71","67.87","1012.10","221","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1189.32","58.3","","293.04","293.04","293.04","11","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1081.20","53","","983.89","983.89","983.89","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1183.20","58","","677.18","677.18","677.18","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1275.00","62.5","","46.58","46.58","46.58","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1489.20","73","","747.15","747.15","747.15","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","906.78","44.45","","1141.67","481.21","1141.67","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","906.78","44.45","","76.54","76.54","76.54","1 through 10","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","WELLPOINT [1015]","HB CH WELLPOINT","1589.36","77.91","","273.64","94.28","1367.51","138","906.78","1589.36","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1209.72","59.3","","720.78","230.14","2010.94","427","1020","1600.38","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1209.72","59.3","","344.45","344.45","344.45","1 through 10","1020","1600.38","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1600.38","78.45","","1120.13","1120.13","1120.13","1 through 10","1020","1600.38","percent of total billed charges",""
"WRIST PLATE 3 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10028335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1600.38","78.45","","456.17","105.33","1284.66","242","1020","1600.38","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","AETNA [1001]","HB CH AETNA HMO / PPO","153.12","58.3","","464.71","67.87","1012.10","221","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.12","58.3","","293.04","293.04","293.04","11","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.20","53","","983.89","983.89","983.89","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","152.34","58","","677.18","677.18","677.18","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","164.16","62.5","","46.58","46.58","46.58","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","191.73","73","","747.15","747.15","747.15","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.75","44.45","","1141.67","481.21","1141.67","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.75","44.45","","76.54","76.54","76.54","1 through 10","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","WELLPOINT [1015]","HB CH WELLPOINT","204.63","77.91","","273.64","94.28","1367.51","138","116.75","204.63","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","155.75","59.3","","720.78","230.14","2010.94","427","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","155.75","59.3","","344.45","344.45","344.45","1 through 10","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","206.05","78.45","","1120.13","1120.13","1120.13","1 through 10","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","206.05","78.45","","456.17","105.33","1284.66","242","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","AETNA [1001]","HB CH AETNA HMO / PPO","108.09","58.3","","464.71","67.87","1012.10","221","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.09","58.3","","293.04","293.04","293.04","11","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.26","53","","983.89","983.89","983.89","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","107.53","58","","677.18","677.18","677.18","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","115.88","62.5","","46.58","46.58","46.58","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.34","73","","747.15","747.15","747.15","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.41","44.45","","1141.67","481.21","1141.67","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.41","44.45","","76.54","76.54","76.54","1 through 10","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","WELLPOINT [1015]","HB CH WELLPOINT","144.45","77.91","","273.64","94.28","1367.51","138","82.41","144.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.94","59.3","","720.78","230.14","2010.94","427","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","109.94","59.3","","344.45","344.45","344.45","1 through 10","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","145.45","78.45","","1120.13","1120.13","1120.13","1 through 10","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.45","78.45","","456.17","105.33","1284.66","242","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","AETNA [1001]","HB CH AETNA HMO / PPO","138.71","58.3","","464.71","67.87","1012.10","221","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.71","58.3","","293.04","293.04","293.04","11","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.10","53","","983.89","983.89","983.89","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","138.00","58","","677.18","677.18","677.18","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","148.71","62.5","","46.58","46.58","46.58","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","747.15","747.15","747.15","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","1141.67","481.21","1141.67","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","76.54","76.54","76.54","1 through 10","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","WELLPOINT [1015]","HB CH WELLPOINT","185.37","77.91","","273.64","94.28","1367.51","138","105.76","185.37","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.09","59.3","","720.78","230.14","2010.94","427","118.97","186.66","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","141.09","59.3","","344.45","344.45","344.45","1 through 10","118.97","186.66","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","1120.13","1120.13","1120.13","1 through 10","118.97","186.66","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","456.17","105.33","1284.66","242","118.97","186.66","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","AETNA [1001]","HB CH AETNA HMO / PPO","2072.57","58.3","","464.71","67.87","1012.10","221","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2072.57","58.3","","293.04","293.04","293.04","11","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1884.15","53","","983.89","983.89","983.89","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","2061.90","58","","677.18","677.18","677.18","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","2221.88","62.5","","46.58","46.58","46.58","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2595.15","73","","747.15","747.15","747.15","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1580.20","44.45","","1141.67","481.21","1141.67","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1580.20","44.45","","76.54","76.54","76.54","1 through 10","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","WELLPOINT [1015]","HB CH WELLPOINT","2769.70","77.91","","273.64","94.28","1367.51","138","1580.2","2769.7","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2108.12","59.3","","720.78","230.14","2010.94","427","1777.5","2788.9","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","2108.12","59.3","","344.45","344.45","344.45","1 through 10","1777.5","2788.9","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","1120.13","1120.13","1120.13","1 through 10","1777.5","2788.9","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","456.17","105.33","1284.66","242","1777.5","2788.9","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","AETNA [1001]","HB CH AETNA HMO / PPO","1364.22","58.3","","464.71","67.87","1012.10","221","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1364.22","58.3","","293.04","293.04","293.04","11","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.20","53","","983.89","983.89","983.89","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1357.20","58","","677.18","677.18","677.18","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1462.50","62.5","","46.58","46.58","46.58","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1708.20","73","","747.15","747.15","747.15","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.13","44.45","","1141.67","481.21","1141.67","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.13","44.45","","76.54","76.54","76.54","1 through 10","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","WELLPOINT [1015]","HB CH WELLPOINT","1823.09","77.91","","273.64","94.28","1367.51","138","1040.13","1823.09","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.62","59.3","","720.78","230.14","2010.94","427","1170","1835.73","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1387.62","59.3","","344.45","344.45","344.45","1 through 10","1170","1835.73","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1835.73","78.45","","1120.13","1120.13","1120.13","1 through 10","1170","1835.73","percent of total billed charges",""
"WRIST PLATE 5 HOLE VOLAR FIXED ANGLE RT 7 PEG","SUP-ITM-10041930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.73","78.45","","456.17","105.33","1284.66","242","1170","1835.73","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","AETNA [1001]","HB CH AETNA HMO / PPO","1619.52","58.3","","464.71","67.87","1012.10","221","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1619.52","58.3","","293.04","293.04","293.04","11","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1472.29","53","","983.89","983.89","983.89","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","1611.19","58","","677.18","677.18","677.18","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1736.19","62.5","","46.58","46.58","46.58","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2027.87","73","","747.15","747.15","747.15","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1234.78","44.45","","1141.67","481.21","1141.67","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1234.78","44.45","","76.54","76.54","76.54","1 through 10","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","WELLPOINT [1015]","HB CH WELLPOINT","2164.27","77.91","","273.64","94.28","1367.51","138","1234.78","2164.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","1647.30","59.3","","720.78","230.14","2010.94","427","1388.96","2179.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1647.30","59.3","","344.45","344.45","344.45","1 through 10","1388.96","2179.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","2179.27","78.45","","1120.13","1120.13","1120.13","1 through 10","1388.96","2179.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2179.27","78.45","","456.17","105.33","1284.66","242","1388.96","2179.27","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","AETNA [1001]","HB CH AETNA HMO / PPO","359.13","58.3","","339.63","339.63","339.63","1 through 10","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL GIC","357.28","58","","48.14","48.14","48.14","1 through 10","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","357.28","58","","56.64","56.64","56.64","1 through 10","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","385.00","62.5","","62.41","62.41","62.41","37","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","273.81","44.45","","460.51","272.90","460.51","1 through 10","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","WELLPOINT [1015]","HB CH WELLPOINT","479.93","77.91","","471.77","471.77","1070.77","19","273.81","479.93","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","616.00","462.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","365.29","59.3","","759.80","48.85","836.38","1 through 10","308","483.25","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","616.00","462.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","483.25","78.45","","460.51","272.90","460.51","25","308","483.25","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","1114.00","835.50","MEDICARE [2001]","HB NWH MEDICARE","651.07","","APC Price ($651.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","325.57","651.14","37","409.67","1870.56","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","1114.00","835.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.12","638.12","1914.36","1 through 10","409.67","1870.56","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","1114.00","835.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","196.69","196.69","638.62","1 through 10","409.67","1870.56","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","outpatient","","","1114.00","835.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","660.60","59.3","","634.64","634.64","634.64","1 through 10","557","1189","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","outpatient","","","1114.00","835.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","873.93","78.45","","832.61","315.70","832.61","1 through 10","557","1189","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","479.00","359.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","284.05","59.3","","273.08","273.08","273.08","1 through 10","99.34","349.67","percent of total billed charges",""
"Xr Angio Ea Add Vessel","PX-32000346","CDM","75774","CPT","0323","RC","","","","both","","","2959.00","2219.25","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","1849.38","62.5","","203.88","203.88","203.88","1 through 10","1568.27","2160.07","percent of total billed charges",""
"Xr Angio Extremity Bilat","PX-32000333","CDM","75716","CPT","0323","RC","","","","both","","","8141.00","6105.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3666.10","3666.10","3666.10","1 through 10","3492.49","9932.12","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","419.00","314.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","1 through 10","99.34","305.87","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","419.00","314.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","328.71","78.45","","625.80","625.80","625.80","1 through 10","110.42","328.71","percent of total billed charges",""
"Xr Aortogram Abdomen W/Ser","PX-32000328","CDM","75625","CPT","0323","RC","","","","both","","","7940.00","5955.00","MEDICARE [2001]","HB NWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","3406.26","9932.12","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","295.00","221.25","AETNA [1001]","HB CH AETNA HMO / PPO","171.99","58.3","","162.73","162.73","162.73","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","295.00","221.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","295.00","221.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","174.94","59.3","","168.18","168.18","168.18","20","131.13","268.9","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.43","78.45","","220.65","220.64","220.65","1 through 10","131.13","268.9","percent of total billed charges",""
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","17","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","320","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","325.00","1 through 10","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","104.56","23","99.34","243.82","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","AETNA [1001]","HB CH AETNA HMO / PPO","329.40","58.3","","311.28","311.28","311.28","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","156","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1025","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","235.18","209","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.60","123.77","143","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","335.05","59.3","","321.71","321.71","321.71","78","199.42","443.24","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","251.14","44.45","","250.12","250.12","250.12","1 through 10","199.42","443.24","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","443.24","78.45","","422.07","250.12","422.07","77","199.42","443.24","percent of total billed charges",""
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","534.00","400.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","outpatient","","","534.00","400.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.66","59.3","","304.13","304.13","304.13","1 through 10","199.42","418.92","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","182.01","182.01","182.01","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","22","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","ELDER SERVICES [1037]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","FALLON HEALTH [1008]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","378.87","378.87","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","193","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","MOLINA [1014]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","118.19","371.88","17","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","246.78","246.78","246.78","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.87","123.76","124.27","15","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","188.11","188.11","254.19","1 through 10","146.69","311.62","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1016.00","762.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.99","119.99","119.99","1 through 10","119.97","741.68","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","AETNA [1001]","HB CH AETNA HMO / PPO","288.00","58.3","","272.16","272.16","272.16","1 through 10","99.34","360.62","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","CHAMPVA [160001]","HB NWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","360.62","other","Tricare OPPS"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","ELDER SERVICES [1037]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.20","97.20","97.20","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","103","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","360.62","73","","350.40","350.40","350.40","1 through 10","99.34","360.62","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","103.07","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.58","44.45","","369.02","369.02","369.02","1 through 10","99.34","360.62","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","104.56","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","494.00","370.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","292.94","59.3","","281.28","281.28","281.28","31","110.42","387.54","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","387.54","78.45","","369.02","218.69","369.02","23","110.42","387.54","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","AETNA [1001]","HB CH AETNA HMO / PPO","402.85","58.3","","381.02","381.02","381.02","1 through 10","119.97","504.43","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","38","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","MOLINA [1014]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.58","252.58","252.58","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","504.43","other","Tricare OPPS"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","119.99","124.27","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","691.00","518.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","409.76","59.3","","393.79","393.79","393.79","1 through 10","199.42","542.09","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","542.09","78.45","","516.63","306.16","516.63","1 through 10","199.42","542.09","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","874.00","655.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","638.02","other","OPPS APC"
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","outpatient","","","874.00","655.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","685.65","78.45","","653.48","653.48","653.48","1 through 10","199.42","685.65","percent of total billed charges",""
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","142.32","142.32","142.32","1 through 10","99.34","234.25","percent of total billed charges",""
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1052.00","789.00","WELLPOINT [1015]","HB CH WELLPOINT","819.61","77.91","","805.71","805.71","805.71","1 through 10","467.61","819.61","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","1052.00","789.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","623.84","59.3","","599.48","599.48","599.48","1 through 10","526","825.29","percent of total billed charges",""
"Xr Change Tube/Drainage Catheter","PX-32000317","CDM","75984","CPT","0320","RC","","","","outpatient","","","1192.00","894.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","706.86","59.3","","2037.51","679.17","2037.51","1 through 10","596","935.12","percent of total billed charges",""
"Xr Change Tube/Drainage Catheter","PX-32000317","CDM","75984","CPT","0320","RC","","","","outpatient","","","1192.00","894.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","935.12","78.45","","891.04","891.04","891.04","1 through 10","596","935.12","percent of total billed charges",""
"Xr Clavicle Cmpl","PX-32000084","CDM","73000","CPT","0320","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","97.40","97.40","97.40","1 through 10","99.34","258.42","other","OPPS APC"
"Xr Cystourethrogram Voiding","PX-32000232","CDM","74455","CPT","0320","RC","","","","outpatient","","","1284.00","963.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1007.30","78.45","","960.23","960.23","960.23","1 through 10","408.67","1007.3","percent of total billed charges",""
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","339.45","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","1583.00","1187.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","15","200.84","1155.59","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","1583.00","1187.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.39","207.19","207.49","1 through 10","200.84","1155.59","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","outpatient","","","1583.00","1187.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","938.72","59.3","","2160.76","901.85","2160.76","1 through 10","357.59","1241.86","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","outpatient","","","1583.00","1187.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1241.86","78.45","","1183.18","1183.18","1183.18","1 through 10","357.59","1241.86","percent of total billed charges",""
"Xr Ercp Catheter Biliary&Pancreas","PX-32000219","CDM","74330","CPT","0320","RC","","","","outpatient","","","1255.00","941.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","744.22","59.3","","1379.55","1379.55","1379.55","1 through 10","627.5","984.55","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","27","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.58","1 through 10","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","196.52","208.03","1 through 10","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","692.07","692.07","692.07","1 through 10","357.59","953.17","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","907.95","907.95","907.95","1 through 10","357.59","953.17","percent of total billed charges",""
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","408.00","306.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","408.00","306.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","outpatient","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","305.21","305.21","305.21","1 through 10","199.42","320.08","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","412.00","309.00","AETNA [1001]","HB CH AETNA HMO / PPO","240.20","58.3","","227.37","227.37","227.37","1 through 10","99.34","300.76","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","412.00","309.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","300.76","other","OPPS APC"
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","outpatient","","","412.00","309.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","323.21","78.45","","143.29","143.29","143.29","1 through 10","110.42","323.21","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1131.00","848.25","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","866.91","other","OPPS APC"
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","499.53","499.53","499.53","1 through 10","402.72","705.86","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","906.00","679.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","644.65","644.64","644.65","1 through 10","402.72","705.86","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","693.88","693.88","693.88","1 through 10","402.72","705.86","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","516.27","516.27","516.27","1 through 10","453","710.76","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","677.31","401.38","677.31","1 through 10","453","710.76","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","AETNA [1001]","HB CH AETNA HMO / PPO","318.32","58.3","","301.08","301.08","301.08","1 through 10","242.7","425.39","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","398.58","73","","387.63","387.63","387.63","1 through 10","242.7","425.39","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","316.68","58","","316.10","316.10","325.52","1 through 10","242.7","425.39","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","341.25","62.5","","358.72","348.33","1076.16","15","242.7","425.39","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","WELLPOINT [1015]","HB CH WELLPOINT","425.39","77.91","","418.22","418.22","418.22","1 through 10","242.7","425.39","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","546.00","409.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","323.78","59.3","","311.17","311.17","311.17","11","273","428.34","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","428.34","78.45","","408.23","241.92","408.23","25","273","428.34","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","413.00","309.75","AETNA [1001]","HB CH AETNA HMO / PPO","240.78","58.3","","227.93","227.93","227.93","1 through 10","99.34","301.49","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.67","102.47","102.97","1 through 10","99.34","301.49","other","OPPS APC"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.00","78.45","","618.12","618.12","618.12","1 through 10","110.42","324","percent of total billed charges",""
"Xr Forearm 2 Views","PX-32000109","CDM","73090","CPT","0320","RC","","","","both","","","351.00","263.25","AETNA [1001]","HB CH AETNA HMO / PPO","204.63","58.3","","193.35","193.35","193.35","1 through 10","99.34","256.23","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.47","104.56","1 through 10","99.34","302.22","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.78","78.45","","619.66","619.66","619.66","1 through 10","110.42","324.78","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1074.00","805.50","AETNA [1001]","HB CH AETNA HMO / PPO","626.14","58.3","","591.95","591.95","591.95","1 through 10","272.7","866.91","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1074.00","805.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.16","263.16","263.16","1 through 10","272.7","866.91","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1074.00","805.50","MEDICARE [2001]","HB NWH MEDICARE","287.03","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","866.91","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1074.00","805.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","636.88","59.3","","611.78","611.78","611.78","1 through 10","408.67","1126.72","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1074.00","805.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","842.55","78.45","","802.63","475.65","802.63","1 through 10","408.67","1126.72","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","outpatient","","","371.00","278.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","220.00","59.3","","211.55","211.55","211.55","1 through 10","110.42","291.05","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","291.05","78.45","","555.08","143.29","555.08","1 through 10","110.42","291.05","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","AETNA [1001]","HB CH AETNA HMO / PPO","271.68","58.3","","256.85","256.85","256.85","1 through 10","99.34","340.18","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","GENERIC COMMERCIAL [1009]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","86.58","86.58","86.58","1 through 10","99.34","340.18","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","52","99.34","340.18","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","outpatient","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","365.58","78.45","","696.54","696.54","696.54","1 through 10","110.42","365.58","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","538.00","403.50","AETNA [1001]","HB CH AETNA HMO / PPO","313.65","58.3","","296.54","296.54","296.54","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.97","124.27","50","119.97","423.04","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","538.00","403.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","319.03","59.3","","612.96","612.96","612.96","1 through 10","199.42","422.06","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","422.06","78.45","","804.16","476.56","804.16","19","199.42","422.06","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","AETNA [1001]","HB CH AETNA HMO / PPO","303.74","58.3","","287.47","287.47","287.47","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","24","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","260","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","380.33","73","","370.11","370.11","370.11","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TRICARE [160005]","HB NWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","123.76","358.94","39","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","124.27","29","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","inpatient","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","367.83","70.6","","90.00","90.00","90.00","1 through 10","291.76","367.83","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","521.00","390.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","308.95","59.3","","297.10","297.10","297.10","71","199.42","408.72","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","521.00","390.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","408.72","78.45","","389.78","389.78","389.78","1 through 10","199.42","408.72","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","408.72","78.45","","389.78","230.99","389.78","52","199.42","408.72","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","22","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.99","117.99","117.99","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.60","124.47","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","725.00","543.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","429.93","59.3","","413.13","413.13","413.13","16","199.42","568.76","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","725.00","543.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","568.76","78.45","","542.00","321.20","542.00","12","199.42","568.76","percent of total billed charges",""
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","461.00","345.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","outpatient","","","461.00","345.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.65","78.45","","344.42","344.42","344.42","1 through 10","199.42","361.65","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","679.00","509.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","495.67","other","OPPS APC"
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","427.00","320.25","AETNA [1001]","HB CH AETNA HMO / PPO","248.94","58.3","","235.31","235.31","235.31","1 through 10","99.34","311.71","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","427.00","320.25","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","311.71","other","OPPS APC"
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","427.00","320.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","253.21","59.3","","243.19","243.19","243.19","1 through 10","110.42","334.98","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","362.00","271.50","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","264.26","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","362.00","271.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.67","59.3","","206.27","206.27","206.27","1 through 10","110.42","283.99","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","362.00","271.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.99","78.45","","270.62","160.37","270.62","1 through 10","110.42","283.99","percent of total billed charges",""
"Xr Nose to Rectum Foreign Body","PX-32000248","CDM","76010","CPT","0320","RC","","","","both","","","355.00","266.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.52","59.3","","202.17","202.17","202.17","1 through 10","99.34","278.5","percent of total billed charges",""
"Xr Nose to Rectum Foreign Body","PX-32000248","CDM","76010","CPT","0320","RC","","","","both","","","355.00","266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.50","78.45","","265.24","265.24","265.24","1 through 10","99.34","278.5","percent of total billed charges",""
"Xr Orbits Cmp 4+ Views|REDUCED SERVICES","PX-32000022","CDM","70200","CPT","0320","RC","","","52","both","","","400.00","300.00","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.14","63.14","63.14","1 through 10","119.97","130.06","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","AETNA [1001]","HB CH AETNA HMO / PPO","169.65","58.3","","160.46","160.46","160.46","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","505.16","31","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.35","44.45","","217.57","217.57","217.57","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.59","124.07","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.35","44.45","","217.57","217.57","217.57","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","291.00","218.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.56","59.3","","165.84","165.84","165.84","14","145.5","268.9","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","228.29","78.45","","217.57","128.93","282.40","18","145.5","268.9","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","334.00","250.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","outpatient","","","334.00","250.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.06","59.3","","190.45","190.45","190.45","1 through 10","167","268.9","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.02","78.45","","249.86","249.86","249.86","1 through 10","167","268.9","percent of total billed charges",""
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","522.00","391.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","297.69","297.69","297.69","1 through 10","199.42","409.51","percent of total billed charges",""
"Xr Ribs W/Cxr 3+ Views Uni","PX-32000049","CDM","71101","CPT","0324","RC","","","","both","","","382.00","286.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.97","124.07","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","686.00","514.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","500.78","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","outpatient","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","538.17","78.45","","303.89","303.89","303.89","1 through 10","199.42","538.17","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","463.00","347.25","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","463.00","347.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.56","59.3","","263.70","263.70","263.70","1 through 10","199.42","363.22","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.22","78.45","","345.96","258.77","345.96","1 through 10","199.42","363.22","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","206.96","206.96","206.96","1 through 10","99.34","273.75","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","273.75","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","12","99.34","273.75","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","99.34","273.75","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","213.89","213.89","213.89","1 through 10","110.42","294.19","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","280.61","280.61","280.61","1 through 10","110.42","294.19","percent of total billed charges",""
"Xr Scapula Cmpl","PX-32000322","CDM","73010","CPT","0320","RC","","","","both","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.90","117.90","117.90","1 through 10","119.13","423.04","other","OPPS APC"
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","384.00","288.00","AETNA [1001]","HB CH AETNA HMO / PPO","223.87","58.3","","211.49","211.49","422.98","1 through 10","99.34","280.32","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","384.00","288.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.67","103.17","14","99.34","280.32","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","492.00","369.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","99.34","359.16","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","outpatient","","","492.00","369.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","291.76","59.3","","280.11","280.11","280.11","1 through 10","110.42","385.97","percent of total billed charges",""
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","610.00","457.50","AETNA [1001]","HB CH AETNA HMO / PPO","355.63","58.3","","336.23","336.23","336.23","1 through 10","119.97","445.3","percent of total billed charges",""
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","610.00","457.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","445.3","other","OPPS APC"
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","outpatient","","","610.00","457.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","478.55","78.45","","455.90","455.90","455.90","1 through 10","199.42","478.55","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","439.00","329.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.14","44.45","","328.28","328.28","328.28","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","both","","","1469.00","1101.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1072.37","other","OPPS APC"
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","both","","","273.00","204.75","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","306.00","229.50","MEDICARE [2001]","HB NWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","outpatient","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","240.06","78.45","","229.10","229.10","229.10","1 through 10","110.42","240.06","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","AETNA [1001]","HB CH AETNA HMO / PPO","651.79","58.3","","1232.66","1232.66","1232.66","1 through 10","170.35","1870.56","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.97","59.3","","963.97","636.98","1736.90","24","496.95","1437.15","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","877.07","78.45","","835.69","495.24","835.69","13","496.95","1437.15","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.95","44.45","","835.69","835.69","835.69","1 through 10","496.95","1437.15","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","634.23","79","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","196.52","207.78","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","196.82","208.03","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1181.00","885.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.33","59.3","","672.73","672.73","672.73","1 through 10","199.42","926.49","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1181.00","885.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","926.49","78.45","","882.58","882.58","882.58","1 through 10","199.42","926.49","percent of total billed charges",""
"Xr Swallow Cine/Video|REDUCED SERVICES","PX-32000199","CDM","74230","CPT","0320","RC","","","52","both","","","1181.00","885.75","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.10","317.10","317.10","1 through 10","200.84","217.73","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","38","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","234.74","234.74","234.74","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.96","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","123.76","124.07","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","inpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","300.76","70.6","","95.00","95.00","95.00","1 through 10","238.56","300.76","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","242.60","414.00","1 through 10","199.42","334.2","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","1 through 10","199.42","334.2","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","ELDER SERVICES [1037]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.99","119.99","119.99","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","MEDICARE [2001]","HB NWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","43","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.99","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","493.00","369.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","292.35","59.3","","280.69","280.69","280.69","1 through 10","199.42","386.76","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","386.76","78.45","","368.26","218.23","368.26","1 through 10","199.42","386.76","percent of total billed charges",""
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","348.00","261.00","AETNA [1001]","HB CH AETNA HMO / PPO","202.88","58.3","","191.65","191.65","191.65","1 through 10","99.34","254.04","percent of total billed charges",""
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","348.00","261.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.69","44.45","","156.37","156.37","156.37","1 through 10","99.34","254.04","percent of total billed charges",""
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","631.00","473.25","MEDICARE [2001]","HB NWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","90.15","460.63","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.48","44.45","","472.04","472.04","472.04","1 through 10","90.15","460.63","percent of total billed charges",""
"Xr Toe(S) 2+ Views","PX-32000192","CDM","73660","CPT","0320","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","99.34","286.16","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","AETNA [1001]","HB CH AETNA HMO / PPO","1005.09","58.3","","950.29","950.29","950.29","1 through 10","200.84","1258.52","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","BLUE CROSS BLUE SHIELD [110001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","TUFTS HEALTH PLAN [170001]","HB NWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.78","207.58","207.78","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","1724.00","1293.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1022.33","59.3","","982.14","982.14","982.14","1 through 10","357.59","1352.48","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1352.48","78.45","","1288.51","763.59","1288.51","1 through 10","357.59","1352.48","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1426.00","1069.50","MEDICARE [2001]","HB NWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","12","200.84","1040.98","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","outpatient","","","1426.00","1069.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.62","59.3","","812.78","812.78","1586.72","1 through 10","357.59","1118.7","percent of total billed charges",""
"Xr Venacavagram Inferior S&I","PX-32000285","CDM","75825","CPT","0320","RC","","","","both","","","7290.00","5467.50","MEDICARE [2001]","HB NWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","1949.7","9932.12","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","ELDER SERVICES [1037]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1807.90","1807.90","1807.90","1 through 10","987.13","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","MEDICARE [2001]","HB NWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","1844.80","3737.85","1 through 10","987.13","4112.05","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","475.00","356.25","AETNA [1001]","HB CH AETNA HMO / PPO","276.93","58.3","","261.95","261.95","261.95","1 through 10","99.34","346.75","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","475.00","356.25","UNITED HEALTHCARE [1016]","HB NWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.276). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","104.56","1 through 10","99.34","346.75","other","OPPS APC"
"Xtroral I&D Absc Cst/Hmtma Floor Mouth Submndb","PX-75000025","CDM","41017","CPT","0761","RC","","","","outpatient","","","4316.00","3237.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2117.86","49.07","","3607.93","3607.93","3607.93","1 through 10","1726.4","3385.9","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","464.71","67.87","1012.10","221","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","293.04","293.04","293.04","11","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","983.89","983.89","983.89","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP COMMERCIAL HMO","261.00","58","","677.18","677.18","677.18","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB NWH MGBHP EMPLOYEE PPO","281.25","62.5","","46.58","46.58","46.58","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","747.15","747.15","747.15","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","1141.67","481.21","1141.67","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","76.54","76.54","76.54","1 through 10","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","273.64","94.28","1367.51","138","200.03","350.6","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","720.78","230.14","2010.94","427","225","353.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","266.85","59.3","","344.45","344.45","344.45","1 through 10","225","353.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1120.13","1120.13","1120.13","1 through 10","225","353.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","456.17","105.33","1284.66","242","225","353.03","percent of total billed charges",""
"Zika Virus Igm Antibody","PX-30003474","CDM","86794","CPT","0302","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB CH AETNA HMO / PPO","102.03","58.3","","96.39","96.39","96.39","1 through 10","16.51","166.25","percent of total billed charges",""
"Zika Virus Mac-Elisa, Igm, S","PX-30003364","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","78.85","percent of total billed charges",""
"Zika Virus Mac-Elisa, Igm, S","PX-30003364","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","47.47","1 through 10","9.6","65.11","percent of total billed charges",""
"Zika Virus Mac-Elisa, Igm, S","PX-30003364","CDM","86790","CPT","0301","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","36.90","36.90","36.90","1 through 10","9.6","65.11","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","54","11.16","91.2","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","96.00","72.00","TRICARE [160005]","HB NWH TRICARE","91.20","95","","13.72","13.72","13.72","1 through 10","11.16","91.2","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.67","44.45","","71.50","41.76","71.50","1 through 10","11.16","91.2","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","60","11.75","75.31","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","34","11.75","75.31","percent of total billed charges",""